Nokea
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
- A. Uterus soft
- B. Contraction duration of 100 seconds
- C. Four contractions in 10 minutes
- D. Early deceleration of fetal heart rate
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds (B) can compromise fetal oxygenation and require discontinuing oxytocin.
You may also like to solve these questions
A patient postdelivery is concerned about getting back to her prepregnancy weight as soon as possible. She had only gained 15 lb during her pregnancy. Which assessment factor would be of concern at her 6-week postpartum checkup?
- A. Patient has lost 30 lb during the 6-week period prior to her scheduled checkup.
- B. Patient states that she is eating healthy and limiting intake of processed foods.
- C. Patient relates increased consumption of fruits and vegetables in her diet postbirth.
- D. Patient has resumed her usual exercise pattern of walking around the neighborhood for 10 minutes each night.
Correct Answer: A
Rationale: The correct answer is (A) because losing 30 lb in the 6-week postpartum period is concerning as it is excessive and may indicate underlying health issues like hyperthyroidism or inadequate nutrition. This rapid weight loss can also affect the mother's energy levels, milk production, and overall health.
Choice (B) is incorrect as eating healthy and limiting processed foods is a positive behavior that supports weight management. Choice (C) is also incorrect as increased consumption of fruits and vegetables is beneficial for overall health. Choice (D) is incorrect because resuming a light exercise routine like walking is generally encouraged postpartum, as long as it is done safely and does not lead to excessive strain.
A pregnant patient arrives for her first prenatal visit at the clinic. She informs the nurse that she has been taking an additional 400 mcg of folic acid prior to becoming pregnant. Based on the patient's history, she has reached 8 weeks' gestation. Which recommendation would the nurse provide regarding folic acid supplementation?
- A. Have the patient continue to take 400 mcg folic acid throughout her pregnancy.
- B. Tell the patient that she no longer has to take additional folic acid because it will be included in her prenatal vitamins.
- C. Have the patient increase her folic acid intake to 1000 mcg throughout the rest of her pregnancy.
- D. Schedule the patient to go for an AFP (alpha-fetoprotein) test.
Correct Answer: B
Rationale: Step 1: The patient has been taking an additional 400 mcg of folic acid prior to pregnancy.
Step 2: Folic acid is crucial in the early stages of pregnancy for neural tube development.
Step 3: By 8 weeks' gestation, the neural tube has already formed.
Step 4: Prenatal vitamins typically contain the recommended amount of folic acid.
Step 5: Therefore, the nurse would recommend the patient to stop taking additional folic acid as it's included in prenatal vitamins.
Which nursing intervention is written correctly?
- A. Force fluids as necessary.
- B. Observe interaction with the infant.
- C. Encourage turning, coughing, and deep breathing.
- D. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
Correct Answer: D
Rationale: Interventions must be detailed and specific; assisting to ambulate within specified timeframes is clear and actionable.
The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client teaching plan?
- A. Insulin production is decreased during pregnancy
- B. Increase daily caloric intake is needed
- C. Injection requirements remain the same
- D. Blood sugars need less monitoring in the first trimester
Correct Answer: B
Rationale: An increase in caloric intake is often necessary to meet the increased metabolic demands of pregnancy, especially in clients with gestational diabetes.
A client at 41-weeks gestation is admitted to the labor and delivery unit for induction of labor. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at -2 station. The Bishop score is 4. What action should the nurse anticipate?
- A. Administration of prostaglandin gel.
- B. Rupture of membranes.
- C. Administration of oxytocin.
- D. Preparation for a cesarean section.
Correct Answer: A
Rationale: A Bishop score of 4 indicates an unfavorable cervix, and prostaglandin gel is typically used to ripen the cervix before induction.