Which of the following findings indicates the nurse should titrate the oxytocin infusion rate to 2 milliunits/min after the first 30 min for a client receiving 1 milliunit/min of oxytocin for labor induction?
The client experiences spontaneous rupture of membranes.
The cervical Bishop score is 2.
The client's contractions palpate as mild.
The monitor indicates contractions every 1 min.
The Correct Answer is C
Choice A reason: Spontaneous rupture of membranes indicates labor progression but does not directly guide oxytocin titration. Oxytocin stimulates uterine contractions, and titration depends on contraction strength and frequency, not membrane status. Rupture enhances labor but lacks specificity for adjusting oxytocin, as it does not reflect myometrial response or contraction adequacy.
Choice B reason: A Bishop score of 2 indicates an unfavorable cervix, suggesting the need for cervical ripening, not immediate oxytocin titration. Oxytocin efficacy depends on contraction patterns, not cervical readiness alone. The score assesses dilation and effacement, but titration requires monitoring uterine response, making this finding irrelevant for adjusting the infusion rate.
Choice C reason: Mild contractions indicate inadequate uterine response to 1 milliunit/min of oxytocin, warranting titration to 2 milliunits/min to achieve an expected labor pattern. Oxytocin stimulates myometrial contractions, and mild intensity suggests insufficient stimulation. Increasing the dose enhances contraction strength and frequency, aligning with labor induction protocols to promote effective labor.
Choice D reason: Contractions every 1 minute indicate hyperstimulation, risking fetal distress due to reduced placental perfusion. Oxytocin titration aims for contractions every 2-3 minutes. This frequency suggests excessive uterine activity, requiring a decrease or pause in oxytocin, not an increase, to prevent hypoxia and ensure fetal safety during labor.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Obtaining the client’s temperature, heart rate, and blood pressure assesses maternal status but is not the highest priority. Nausea and an urgent need for a bowel movement suggest advanced labor or fetal head compression. Fetal heart rate (FHR) monitoring is critical, as strong contractions may reduce placental perfusion, risking fetal hypoxia, which takes precedence over maternal vital signs to ensure immediate fetal safety.
Choice B reason: Examining vaginal discharge for meconium indicates potential fetal stress but is not the highest priority. Nausea and bowel urgency suggest rapid labor progression or fetal head compression, impacting FHR. Assessing FHR first ensures fetal oxygenation status, as meconium is a secondary finding that does not immediately guide interventions for acute distress during strong contractions.
Choice C reason: Determining the fetal heart rate in relationship to contractions is the highest priority, as nausea and bowel urgency indicate possible second-stage labor or fetal head compression, causing FHR decelerations. Strong contractions may reduce placental blood flow, risking hypoxia. Continuous monitoring via scalp electrode detects late or variable decelerations, guiding urgent interventions to ensure fetal safety.
Choice D reason: Performing a sterile vaginal examination assesses labor progress but is not the highest priority. Nausea and bowel urgency suggest advanced labor, but FHR assessment takes precedence to rule out fetal distress. Vaginal exams risk infection or membrane rupture and do not directly address fetal oxygenation, critical during strong contractions that may compromise placental perfusion.
Correct Answer is C
Explanation
Choice A reason: Tightening gluteal muscles during a Sitz bath is not recommended, as it may increase pelvic tension and reduce the bath’s therapeutic effect. Sitz baths promote perineal healing by improving blood flow and relaxing tissues. Muscle contraction could counteract vasodilation, impeding tissue repair and pain relief in the postpartum period.
Choice B reason: Placing a bag above the toilet bowl is irrelevant to Sitz bath administration, which involves soaking the perineal area in warm water. This instruction likely refers to perineal irrigation devices, not Sitz baths. The bath’s warm water promotes vasodilation and healing, and improper equipment use does not support the physiological benefits of soaking.
Choice C reason: Rinsing with a clean towel after a Sitz bath ensures hygiene by removing residual bacteria or debris from the perineal area. This practice supports wound healing and infection prevention, as warm water soaks soften tissues and promote circulation. Proper drying with a clean towel minimizes moisture-related bacterial growth, enhancing postpartum recovery.
Choice D reason: Remaining in a Sitz bath for 45 minutes is excessive and may cause skin maceration or discomfort. Typical Sitz baths last 10-20 minutes to promote perineal blood flow and healing without overexposure to moisture. Prolonged soaking risks skin breakdown, counteracting the therapeutic benefits of warmth and hygiene in postpartum care.
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