A client with pre-eclampsia with severe features at 38 weeks' gestation is being induced with IV oxytocin.
Which of the following would warrant the nurse to stop the infusion?
Blood pressure 160/110.
Frequency of contractions every 3 minutes.
Fetal heart rate 155 bpm with early decelerations.
Frequency of contractions every 3 minutes.
The Correct Answer is A
Choice A rationale
Blood pressure of 160/110 indicates severe preeclampsia and warrants immediate intervention to prevent complications. Stopping oxytocin is part of the management of severe
preeclampsia to avoid exacerbating the condition.
Choice B rationale
Frequency of contractions every 3 minutes is within the normal range during labor induction and does not warrant stopping the infusion unless there are other concerns.
Choice C rationale
A fetal heart rate of 155 bpm with early decelerations may require close monitoring but does not necessarily warrant stopping the oxytocin infusion. Early decelerations are typically a
normal physiological response.
Choice D rationale
Frequency of contractions every 3 minutes is expected during active labor and is generally not a cause to stop the oxytocin infusion. The nurse should continue to monitor the labor
progression closely.
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Correct Answer is A
Explanation
Choice A rationale
A 37-year-old patient with obesity and pregnancy-induced hypertension presents multiple risk factors. Advanced maternal age, obesity, and hypertension collectively increase the
likelihood of complications such as preeclampsia, gestational diabetes, and cesarean delivery, necessitating close monitoring and management.
Choice B rationale
A patient with preexisting hypertension and twins is indeed high-risk due to the combined strain on the cardiovascular system and potential for preterm labor or other complications
associated with multiple gestations. However, the presence of pregnancy-induced hypertension and obesity in the first patient poses a slightly higher cumulative risk.
Choice C rationale
A 16-year-old patient with newly diagnosed gestational diabetes is at increased risk, particularly because of age and the potential for poorly managed diabetes leading to
complications. However, this scenario presents fewer immediate cumulative risks compared to older age and existing hypertension.
Choice D rationale
A 28-year-old patient who had a premature birth three years prior must be monitored for signs of recurrent preterm labor. Yet, this history alone does not present as high a cumulative
risk as older maternal age, obesity, and pregnancy-induced hypertension. .
Correct Answer is B
Explanation
Choice A rationale
Contraction duration less than 40 seconds doesn't define tachysystole. Tachysystole focuses on frequency, not duration, of contractions over a specific time frame.
Choice B rationale
Contraction frequency of more than 5 in 10 minutes defines tachysystole. This frequency indicates excessive uterine activity, requiring intervention to prevent fetal distress.
Choice C rationale
Contraction intensity less than 80 mm Hg does not define tachysystole. Intensity relates to contraction strength, but tachysystole is about frequency exceeding the normal range.
Choice D rationale
Resting tone less than 18 mm Hg isn't part of tachysystole's definition. Tachysystole pertains to contraction frequency, not resting tone, which measures uterine relaxation between contractions.