Nokea
Client receiving oxytocin (Pitocin) infusion
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
- A. Measuring urinary output.
- B. Evaluating cervical dilation.
- C. Increasing infusion rate every 30 minutes.
- D. Monitoring uterine response.
Correct Answer: D
Rationale: Monitoring uterine response is critical as oxytocin can cause excessive contractions, risking fetal distress, uterine rupture, or placental abruption.
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Male newborn, genitalia assessment
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?
- A. Inspecting if the urethral opening appears circular.
- B. Retracting the foreskin over the glans to assess for secretions.
- C. Palpating if testes are descended into the scrotal sac.
- D. Inspecting the genital area for irritated skin.
Correct Answer: B
Rationale: Retracting the foreskin over the glans should be avoided as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans and should not be forcibly retracted.
Woman receiving oxytocin stimulation
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because
- A. It produces a prolapsed cord.
- B. It increases maternal renal blood flow.
- C. It decreases maternal blood pressure.
- D. There is a reduction of placental blood flow.
Correct Answer: D
Rationale: Hypertonic contractions reduce placental blood flow by limiting the time for the placenta to refill with blood between contractions, risking fetal hypoxia. Note: The document incorrectly lists 'A' as the correct answer, but the explanation supports 'D' as the correct choice based on standard medical understanding.
Client considered for amniotomy
The nurse understands which condition is a contraindication for an amniotomy.
- A. Right occiput posterior position.
- B. -2 station.
- C. Cephalic presentation.
- D. Dilation less than 3 cm.
Correct Answer: D
Rationale: Dilation less than 3 cm is a contraindication for amniotomy due to increased risks of infection and cord compression.
Mother in labor, nonreassuring fetal heart rate pattern, lying on left side
The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?
- A. Change her position to the right side.
- B. Place a wedge under the left hip.
- C. Lower the head of the bed.
- D. Place the mother in a Trendelenburg position.
Correct Answer: B
Rationale: Placing a wedge under the left hip is a common intervention to improve uteroplacental blood flow by tilting the uterus off the vena cava, enhancing venous return and cardiac output, which can positively affect fetal oxygenation.
Pregnant woman educated about placental hormones
After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?
- A. Human placental lactogen (hPL).
- B. Estrogen (estriol).
- C. Progesterone (progestin).
- D. Human chorionic gonadotropin (hCG).
Correct Answer: D
Rationale: Human chorionic gonadotropin (hCG) is produced by the fertilized egg and detected in pregnancy tests, indicating fertilization and implantation.