The nurse turns off the oxytocin infusion after a period of tachysystole.
Which of the following outcomes indicates that the nurse's action was effective?
Uterine contraction duration of 130 seconds.
Uterine contraction frequency every three to four minutes.
Intensity of the contractions are strong.
Fetus has a flexed attitude.
The Correct Answer is B
Choice A rationale
A uterine contraction duration of 130 seconds is too long and indicates uterine hyperstimulation, which is not an effective outcome.
Choice B rationale
Uterine contraction frequency every three to four minutes is a normal and effective pattern, indicating that the nurse's intervention to stop oxytocin was successful.
Choice C rationale
The intensity of contractions being strong is important but does not directly indicate effective management of tachysystole.
Choice D rationale
Fetal flexed attitude refers to the fetal position and does not indicate the effectiveness of managing tachysystole.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
The condition of uterine rupture is correct because the client, with a history of previous cesarean section and sudden onset of lower pelvic pain with significant hypotension and tachycardia, is at risk of uterine rupture. The absence of contractions on the external fetal monitor and the pain rating of 8 indicate a possible disruption of the uterine wall. Preparing for an emergency cesarean delivery is critical to prevent further maternal and fetal complications. Administering IV fluids and oxygen helps to stabilize the client’s hemodynamic status. Monitoring maternal blood pressure is essential to assess for shock, and continuous fetal heart rate monitoring is necessary to detect fetal distress.
Actions and Parameters Rationale:
- Preparing for emergency cesarean delivery is crucial as it addresses the immediate need to deliver the baby safely and manage the rupture.
- Administering IV fluids and oxygen helps to maintain maternal circulation and oxygenation, which is vital in preventing shock and ensuring fetal well-being.
- Monitoring maternal blood pressure is essential to detect signs of hypovolemic shock, which is a risk with uterine rupture.
- Continuous monitoring of fetal heart rate is necessary to detect any signs of fetal distress, which can occur with uterine rupture.
Incorrect Conditions:
- Prolapsed Umbilical Cord (B): There is no indication of a prolapsed cord, such as sudden fetal distress or visible/palpable cord.
- Placental Abruption (C): There are no signs of placental abruption, such as vaginal bleeding, uterine tenderness, or abnormal fetal heart rate patterns.
- Pre-eclampsia (D)
Correct Answer is ["7"]
Explanation
Step 1 is to assess each parameter: Cervical dilation: 2 cm = 1 point Effacement: 60% = 1 point Station: -1 = 1 point Cervix consistency: Soft = 2 points Cervix position: Anterior = 2 points.
Final calculated answer: Bishop score = 7.
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