Which client status is an acceptable indication for oxytocin induction of labor?
Past 42 weeks of gestation.
Polyhydramnios.
History of long labors.
Multiple fetuses.
The Correct Answer is A
Choice A rationale
Post-term pregnancy, defined as a gestation extending past 42 weeks, is a valid indication for oxytocin induction. This is because the risk of placental insufficiency, fetal macrosomia, oligohydramnios, and subsequent fetal distress or stillbirth increases significantly after the estimated due date has passed the 42-week mark.
Choice B rationale
Polyhydramnios, an excess of amniotic fluid, is not a standard indication for oxytocin induction; it is often associated with conditions like gestational diabetes or fetal anomalies. While it can cause maternal discomfort or uterine overdistension, induction is usually only necessary if associated complications threaten maternal or fetal well-being.
Choice C rationale
A history of long labors is a retrospective observation, not a medical indication for the induction of labor in the current pregnancy. Labor induction is based on current maternal or fetal health risks, not prior labor patterns. Oxytocin induction itself carries risks, and a prior long labor does not necessitate intervention this time.
Choice D rationale
Multiple fetuses (e.g., twins) is not an acceptable indication for routine oxytocin induction and often presents a relative contraindication. Multiple gestations carry a higher risk of complications like preterm labor and uterine overdistension, and labor management often requires careful monitoring, sometimes leading to a Cesarean section.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The expected uterine discharge 5 days postpartum is lochia serosa, which is typically thin, watery, and a pinkish-brown color. This stage follows lochia rubra (deep red, 1-3 days postpartum) and consists of old blood, serum, tissue debris, and leukocytes. It usually lasts from about day 4 to day 10 postpartum, representing a normal progression of the uterine healing process (involution).
Choice B rationale
A deep red, mucus-like discharge (lochia rubra) is characteristic of the first 3 to 4 days postpartum, consisting mainly of blood, decidual and trophoblastic debris. By day 5, the discharge should have transitioned to lochia serosa as the bleeding significantly lessens and the wound-healing process progresses within the uterine cavity.
Choice C rationale
Creamy white or yellowish discharge (lochia alba) is the final stage of lochia, consisting primarily of leukocytes, decidual cells, epithelial cells, fat, and mucus. This stage typically begins around day 10 to 14 postpartum and can last for several weeks, indicating that the uterine lining has healed and involution is nearly complete.
Choice D rationale
Bright red discharge (lochia rubra) or a sudden return to bright red bleeding after the lochia has progressed (secondary hemorrhage) is abnormal 5 days postpartum. It suggests active bleeding at the placental site or cervical/vaginal lacerations. If heavy, it warrants immediate assessment for possible retained placental fragments or uterine atony.
Correct Answer is C
Explanation
Choice A rationale
The Babinski reflex is assessed by stroking the sole of the foot from the heel up and across the ball, which should cause the toes to curl downward (plantar flexion) in a normal infant. A positive Babinski sign in an adult (toes fanning out) indicates neurological impairment, but in a newborn, a transient fanning and dorsiflexion of the big toe is often a normal finding due to immature central nervous system myelination. This is not the reflex described.
Choice B rationale
The Glabellar reflex (or blink reflex) is elicited by gently tapping the newborn's forehead or glabella (the skin between the eyebrows). A positive response involves the newborn blinking in response to the tap. This is a brainstem-mediated, protective reflex that persists throughout life. It is tested to assess neurological integrity but is unrelated to the described startle reaction with arm and hand movements.
Choice C rationale
The Moro reflex, also known as the startle reflex, is a primitive reflex typically present from birth to about 6 months of age. It is triggered by a sudden loud noise or loss of head support. The characteristic response involves symmetrical abduction and extension of the arms, fanning of the fingers with the thumb and forefinger forming a 'C' shape, followed by adduction of the arms, sometimes accompanied by a tremor, exactly as described.
Choice D rationale
The Tonic neck reflex (or fencing posture) is observed when the infant's head is turned quickly to one side while they are supine. The reflex involves the arm and leg on the side to which the head is turned extending, and the opposite arm and leg flexing. This is a different, posture-regulating reflex, unrelated to the sudden startle response described by the nurse.
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