Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on the labor and delivery unit is caring for a patient undergoing labor induction 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.
What action should the nurse take?
A. Slow the client’s rate of breathing.
Slowing the client’s rate of breathing would not directly address the issue of strong, frequent contractions and uniform decelerations of the fetal heart rate. These symptoms suggest uterine hyperstimulation, which can compromise fetal oxygenation.
B. Increase the rate of infusion of the IV oxytocin.
Increasing the rate of infusion of the IV oxytocin would likely exacerbate the problem, as oxytocin can cause uterine hyperstimulation, leading to reduced fetal oxygen supply.
C. Discontinue the infusion of the IV oxytocin.
Discontinuing the infusion of the IV oxytocin is the appropriate action. The pattern of contractions and fetal heart rate decelerations suggest uterine hyperstimulation, which can be caused by excessive oxytocin. Stopping the oxytocin infusion can help to normalize the contraction pattern and improve fetal oxygenation.
D. Decrease the rate of infusion of the maintenance IV solution.
Decreasing the rate of infusion of the maintenance IV solution would not directly address the issue of uterine hyperstimulation and fetal heart rate decelerations.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 232 Maternity Final Proctored Exam Sp24. Take the full exam now
Full Explanation
Choice A rationale
Slowing the client’s rate of breathing would not directly address the issue of strong, frequent contractions and uniform decelerations of the fetal heart rate. These symptoms suggest uterine hyperstimulation, which can compromise fetal oxygenation.
Choice B rationale
Increasing the rate of infusion of the IV oxytocin would likely exacerbate the problem, as oxytocin can cause uterine hyperstimulation, leading to reduced fetal oxygen supply.
Choice C rationale
Discontinuing the infusion of the IV oxytocin is the appropriate action. The pattern of contractions and fetal heart rate decelerations suggest uterine hyperstimulation, which can be caused by excessive oxytocin. Stopping the oxytocin infusion can help to normalize the contraction pattern and improve fetal oxygenation.
Choice D rationale
Decreasing the rate of infusion of the maintenance IV solution would not directly address the issue of uterine hyperstimulation and fetal heart rate decelerations.
Similar Questions
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and believes she is in labor.
Which finding confirms to the nurse that the client is in labor?
A. Cervical dilation.
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
B. Amniotic fluid in the vaginal vault
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
C. Report of pain above the umbilicus.
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.
Full Explanation
Choice A rationale
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
Choice B rationale
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
Choice C rationale
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Choice D rationale
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.
A nurse in a prenatal clinic is caring for a client who believes she might be pregnant because she feels the baby moving.Which statement should the nurse make?
A. “This is a probable sign of pregnancy.”.
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
B. “This is a possible sign of pregnancy.”.
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
C. “This is a presumptive sign of pregnancy.”.
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
D. “This is a positive sign of pregnancy.”.
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
Full Explanation
Choice A rationale
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
Choice B rationale
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
Choice C rationale
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
Choice D rationale
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Moro reflex, what action should the nurse take?
A. Turn the newborn’s head quickly to one side.
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
B. Perform a sharp hand clap near the infant.
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
C. Place a finger at the base of the newborn’s toes.
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
D. Hold the newborn vertically allowing one foot to touch the table surface.
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.
Full Explanation
Choice A rationale
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
Choice B rationale
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
Choice C rationale
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
Choice D rationale
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.