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Client receiving oxytocin to augment labor, nurse notes recurrent variable decelerations of the FHR.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the necessary equipment to initiate an amnioinfusion.
- B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- C. Discontinue the infusion of oxytocin.
- D. Provide instructions for the client about potential preparation for birth.
Correct Answer: C
Rationale: Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.
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Client in labor with an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring, receiving oxytocin.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 minutes.
- B. Contraction duration of 100 seconds.
- C. Fetal heart rate of 118/min.
- D. Fetal heart rate with moderate variability.
Correct Answer: B
Rationale: Contraction duration of 100 seconds exceeds the normal range (usually less than 90 seconds), risking uterine hyperstimulation and fetal compromise, necessitating oxytocin discontinuation.
Newborn
Complete the following sentence using the lists of options: The nurse should [option] intramuscular ceftriaxone [purpose].
- A. The nurse should prescribe intramuscular ceftriaxone to decrease the risk of ophthalmia neonatorum in a newborn.
- B. The nurse should identify ceftriaxone as a suitable medication for bacterial infections.
- C. The nurse should use intramuscular ceftriaxone to treat gonorrhea effectively.
- D. The nurse should select intramuscular ceftriaxone for prophylaxis against postpartum infections.
Correct Answer: A
Rationale: Intramuscular ceftriaxone is effective in preventing ophthalmia neonatorum, caused by Neisseria gonorrhoeae. This bacterial prophylaxis inhibits cell wall synthesis, reducing infection transmission from mother to newborn.
Newborn with hyperbilirubinemia and a prescription for phototherapy.
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hours.
- B. Apply moisturizing lotion to the newborn's skin every 4 hours.
- C. Reposition the newborn every 2 to 3 hours.
- D. Give the newborn 1 oz of glucose water every 4 hours.
Correct Answer: C
Rationale: Repositioning every 2-3 hours evenly exposes all skin areas to light, optimizing bilirubin breakdown and preventing pressure ulcers, ensuring effective phototherapy outcomes and skin integrity.
Client reports intermittent dark brown vaginal discharge for the past three days.
A client reports an intermittent dark brown vaginal discharge for the past three days. What should the nurse do?
- A. The nurse should assess the client for signs of molar pregnancy.
- B. The nurse should evaluate the risk for hypovolemic shock due to blood loss.
- C. The nurse should ensure appropriate laboratory testing for the diagnosis of choriocarcinoma.
- D. The nurse should prioritize preparing the client for suction and curettage.
Correct Answer: A
Rationale: Molar pregnancy often manifests as intermittent dark brown vaginal discharge due to trophoblastic tissue expulsion. It warrants assessment as it correlates with hCG elevation and abnormal placental development.
Pregnant client with hypertension.
For each of the following potential antihypertensive medications, indicate whether it is recommended or not recommended for use in a pregnant client.
- A. Methyldopa.
- B. Lisinopril.
- C. Labetalol.
- D. Losartan.
- E. Hydralazine.
Correct Answer: A,C,E
Rationale: Methyldopa (A) is safe and effective for pregnancy-induced hypertension. Labetalol (C) is recommended for hypertensive crises with a favorable safety profile. Hydralazine (E) is safe for severe hypertensive emergencies. Lisinopril (B) and Losartan (D) are contraindicated due to teratogenic risks.