Nokea
The nurse is monitoring a laboring client with oxytocin infusion. What finding requires immediate intervention?
- A. Contractions lasting 60 seconds.
- B. Contractions every 2 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Client reports back pain.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, requiring immediate intervention to ensure fetal well-being.
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A client, who is in the second trimester of pregnancy, gestation. The client is receiving magnesium sulfate tells the nurse that she has developed a reddish-pink intravenously for pre-eclampsia. Which assessment skin color on the palm of her hands. Which of the fol- requires immediate intervention?
- A. Blood pressure of 130/90 mm Hg
- B. Urine output of 20 mL in past hour
- C. Facial flushing
- D. Patellar reflexes 2+
Correct Answer: C
Rationale: Facial flushing in a pregnant client receiving magnesium sulfate for pre-eclampsia can be a sign of magnesium toxicity. Magnesium sulfate is a tocolytic agent used to prevent seizures in pre-eclamptic patients; however, excessive levels of magnesium can cause symptoms such as flushing, lethargy, blurred vision, slurred speech, and muscle weakness. In severe cases, magnesium toxicity can progress to respiratory depression, cardiac arrest, and death. Therefore, immediate intervention is required to prevent further complications. The other options do not present immediate concerning signs related to magnesium toxicity.
The nurse is educating a client about the benefits of skin-to-skin contact after delivery. What is one of the key benefits?
- A. Prevents postpartum hemorrhage.
- B. Improves maternal milk production.
- C. Reduces the risk of neonatal jaundice.
- D. Stabilizes neonatal temperature and heart rate.
Correct Answer: D
Rationale: Skin-to-skin contact helps stabilize the newborn's temperature and heart rate while promoting bonding.
What statement best describes social determinants of health (SDOH)?
- A. genetic factors that influence an individual's health outcomes and risks
- B. medical interventions and treatments provided by health-care professionals
- C. conditions in the environments where people live, work, and play that impact health outcomes and risks
- D. personal self-care practices, such as diet and exercise, that affect individual well-being
Correct Answer: C
Rationale:
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, 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 rate of breathing.
Correct Answer: B
Rationale: The described scenario suggests the presence of late decelerations, which occur when uteroplacental insufficiency leads to decreased fetal oxygenation. In this case, the late decelerations are evident with each contraction, indicating a potential adverse reaction to the oxytocin infusion. The appropriate action would be to discontinue the infusion of IV oxytocin to prevent further compromise to fetal well-being. Alternatively, the nurse should consider repositioning the mother, administering oxygen via a face mask, and notifying the healthcare provider for further assessment and interventions.
What technique is used for visualization and deepening in HypnoBirthing?
- A. counting contractions
- B. the on-off†switch
- C. visualizing the instruments used to assist with birth
- D. deepening into hypnosis to help push harder
Correct Answer: B
Rationale: The 'on-off' switch is a visualization technique used in HypnoBirthing to deepen relaxation.