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Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
- A. Notify the health care provider.
- B. Turn off the oxytocin (Pitocin) infusion.
- C. Turn the client to her left side.
- D. Increase the maintenance I.V. fluids.
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.
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A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.
A multigravid client at 40 weeks' gestation with a history of previous cesarean delivery is admitted for a trial of labor. The fetal monitor shows late decelerations. Which interventions should the nurse perform? Select all that apply.
- A. Administer oxygen at 8–10 L/min via mask.
- B. Stop the oxytocin infusion.
- C. Reposition the client to her right side.
- D. Increase the IV fluid rate.
- E. Apply a fetal scalp electrode.
Correct Answer: A,B,D
Rationale: Late decelerations suggest uteroplacental insufficiency. Administering oxygen, stopping oxytocin (if running), and increasing IV fluids improve fetal oxygenation and uterine perfusion. Right-side repositioning is less effective than left-side, and scalp electrodes are not the first step.
A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which of the following?
- A. Conjunctivitis.
- B. Heart disease.
- C. Skin lesions.
- D. Hepatitis.
Correct Answer: A
Rationale: Untreated chlamydia during delivery can cause neonatal conjunctivitis (ophthalmia neonatorum) via transmission through the birth canal. Heart disease, skin lesions, and hepatitis are not associated with chlamydia.
Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician?
- A. Alkalosis.
- B. Increased muscle tone.
- C. Temperature instability.
- D. Positive Babinski's reflex.
Correct Answer: C
Rationale: Temperature instability can indicate early sepsis, especially in a neonate at risk due to maternal beta-hemolytic Streptococcus.
After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at delivery, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following?
- A. Cardiac decompensation.
- B. Polycythemia.
- C. Splenomegaly.
- D. Reduced bilirubin levels.
Correct Answer: D
Rationale: Hemolysis due to Rh sensitization causes increased bilirubin levels, not reduced levels, indicating a need for further instruction.