Nokea
A patient on the labor and delivery unit is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's breathing rate.
Correct Answer: B
Rationale: The correct answer is B: Discontinue the infusion of the IV oxytocin. Decelerations starting at the peak of contractions indicate uteroplacental insufficiency, which can be caused by hyperstimulation from oxytocin. Stopping the oxytocin infusion will help alleviate this issue and improve fetal oxygenation. Choice A would not address the underlying cause of the decelerations. Choice C would worsen the hyperstimulation. Choice D is not directly related to the fetal heart rate decelerations.
You may also like to solve these questions
A client is 1 hour postpartum and the nurse observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Notify the healthcare provider.
- B. Increase the frequency of fundal massage.
- C. Encourage the client to empty their bladder.
- D. Document the findings and continue to monitor the client.
Correct Answer: D
Rationale: Rationale:
1. Lochia rubra and small clots are expected postpartum.
2. The firm, midline fundus indicates normal involution.
3. No signs of excessive bleeding or fundus displacement.
4. Documenting and monitoring is appropriate for normal postpartum assessment.
Summary:
A: Not necessary as no complications present.
B: Unnecessary and could cause discomfort.
C: Bladder emptying may help fundal position but not urgent.
D: Correct option for normal postpartum assessment and monitoring.
A client is scheduled for a cesarean birth based on fetal lung maturity. Which finding indicates that the fetal lungs are mature?
- A. Absence of Phosphatidylglycerol (PG)
- B. Biophysical profile score of 8
- C. Lecithin/sphingomyelin (L/S) ratio of 2:1
- D. Reactive nonstress test
Correct Answer: C
Rationale: The correct answer is C: Lecithin/sphingomyelin (L/S) ratio of 2:1. This ratio indicates fetal lung maturity as it signifies adequate production of surfactant in the fetal lungs, essential for proper lung function after birth. Absence of Phosphatidylglycerol (PG) (Choice A) indicates immaturity, Biophysical profile score of 8 (Choice B) assesses overall fetal well-being, not lung maturity, and Reactive nonstress test (Choice D) evaluates fetal well-being, not lung maturity. The L/S ratio of 2:1 is the most reliable indicator of fetal lung maturity.
A healthcare professional in the emergency department is caring for a client who presents with severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the healthcare professional that the client has blood in the peritoneum?
- A. Chvostek's sign
- B. Cullen's sign
- C. Chadwick's sign
- D. Goodell's sign
Correct Answer: B
Rationale: The correct answer is B: Cullen's sign. Cullen's sign is the presence of periumbilical ecchymosis, indicating blood in the peritoneum due to internal bleeding from a ruptured ectopic pregnancy. Chvostek's sign (choice A) is related to facial muscle spasm due to hypocalcemia. Chadwick's sign (choice C) is bluish discoloration of the cervix indicating pregnancy. Goodell's sign (choice D) is softening of the cervix in early pregnancy. These signs are not indicative of blood in the peritoneum like Cullen's sign is.
A client at 36 weeks of gestation is suspected of having placenta previa. Which of the following findings support this diagnosis?
- A. Painless red vaginal bleeding
- B. Increasing abdominal pain with a non-relaxed uterus
- C. Abdominal pain with scant red vaginal bleeding
- D. Intermittent abdominal pain following the passage of bloody mucus
Correct Answer: A
Rationale: The correct answer is A: Painless red vaginal bleeding. This finding supports the diagnosis of placenta previa due to the characteristic symptom of painless bleeding in the third trimester. Placenta previa occurs when the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to dilate. The other choices are incorrect because increasing abdominal pain with a non-relaxed uterus (B) may indicate placental abruption, abdominal pain with scant red vaginal bleeding (C) is not typical of placenta previa, and intermittent abdominal pain following the passage of bloody mucus (D) is more suggestive of preterm labor or bloody show.
A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. Fertilization takes place in the outer third of the fallopian tube.
- B. Implantation occurs between 6 to 10 days after conception.
- C. Sperm remain viable in the woman's reproductive tract for 2 to 3 days.
- D. Bleeding or spotting can accompany implantation.
Correct Answer: B
Rationale: The correct answer is B because implantation actually occurs around 6-10 days after fertilization, not after conception. This is a critical distinction as conception refers to the union of sperm and egg to form a zygote, while fertilization specifically refers to the fusion of the genetic material. Therefore, the statement by the newly licensed nurse is inaccurate and requires intervention.
A: Fertilization typically occurs in the outer third of the fallopian tube, making this statement correct.
C: Sperm can indeed remain viable in the woman's reproductive tract for 2 to 3 days, indicating this statement is accurate.
D: Bleeding or spotting can indeed accompany implantation, making this statement correct.
In summary, choice B is incorrect because implantation occurs around 6-10 days after fertilization, not conception. Choices A, C, and D are all correct statements related to conception and fertilization.