Nokea
The nurse is monitoring a client receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2 minutes.
- B. Fetal heart rate of 100 beats/minute.
- C. Maternal blood pressure of 120/80 mmHg.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: A fetal heart rate of 100 bpm indicates bradycardia and requires immediate discontinuation of oxytocin.
You may also like to solve these questions
The woman with the lowest risk for sexually trans-
- A. Red swollen area around distal suture repair of mitted pelvic inflammatory disease is one who uses episiotomy site which of the following?
- B. Oral contraceptives
- C. A barrier method of contraception
- D. An intrauterine device for contraception
Correct Answer: C
Rationale: The lowest risk for sexually transmitted pelvic inflammatory disease is associated with using a barrier method of contraception, such as condoms. Barrier methods create a physical barrier that helps prevent the exchange of bodily fluids, reducing the risk of transmission of sexually transmitted infections, including pelvic inflammatory disease. Oral contraceptives, intrauterine devices, and birth control patches do not provide the same level of protection against sexually transmitted infections as barrier methods like condoms.
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?
- A. Document the finding.
- B. Check the mother's heart rate.
- C. Notify the health care provider (HCP).
- D. Tell the client that the fetal heart rate is normal.
Correct Answer: C
Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.
Which of the following best describes the mechanism of action of birth control pills?
- A. They block sperm from reaching the egg.
- B. They prevent ovulation by suppressing hormone levels.
- C. They increase cervical mucus production to block sperm entry.
- D. They reduce the size of the ovaries and fallopian tubes to prevent pregnancy.
Correct Answer: B
Rationale: Birth control pills primarily work by preventing ovulation, thereby inhibiting the release of eggs for fertilization. Choice A is incorrect because birth control pills do not directly block sperm; they prevent ovulation. Choice C is partially correct but is not the main mechanism, as the primary function is to prevent ovulation. Choice D is incorrect because birth control pills do not alter the size of reproductive organs.
A client is experiencing uterine atony after delivery. What is the nurse's first action?
- A. Massage the fundus until firm.
- B. Increase IV fluid rate.
- C. Notify the healthcare provider.
- D. Administer prescribed oxytocin.
Correct Answer: A
Rationale: Fundal massage stimulates uterine contraction and is the initial response to uterine atony to prevent hemorrhage.
A male infant delivered at 28 weeks gestation weighs 2 pounds, 12 ounces. When performing an assessment, the nurse would probably observe:
- A. Wide, staring eye
- B. Transparent, red skin
- C. An absence of lanugo
- D. A scrotum with descended testicles
Correct Answer: B
Rationale: A male infant delivered at 28 weeks gestation, as described, would likely have very underdeveloped skin due to the premature birth. The premature skin is often transparent, allowing the prominent blood vessels underneath to be visible, and may also have a reddish hue due to the skin's immaturity. This characteristic appearance is a common finding in premature infants and is a result of their skin being thinner and more fragile than that of full-term infants. The other options, such as a wide, staring eye, an absence of lanugo, and a scrotum with descended testicles, are not specifically associated with premature birth and are not likely to be observed in this scenario.