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 ["B","C","E"]
Explanation
Choice A rationale
Pumping up the vacuum manually to the pressure indicated on the pump is a standard procedure but doesn't directly minimize liability.
Choice B rationale
Recognizing cup detachment (pop off) as a warning sign is critical, as it indicates excessive force or poor positioning, which can lead to fetal or maternal injury.
Choice C rationale
Limiting the cup's attachment to the fetal head to 5 to 10 minutes reduces the risk of scalp injury and other complications, thus minimizing liability.
Choice D rationale
Timing the procedure from insertion of the cup into the vagina until the birth is a guideline but doesn't specifically address liability concerns.
Choice E rationale
Releasing pressure between contractions prevents continuous suction on the fetal head, reducing the risk of injury and thereby minimizing liability.
Correct Answer is D
Explanation
Choice A rationale
Bleeding is typically not associated with a vaginal hematoma; it is more indicative of other postpartum complications such as uterine atony or retained placenta fragments.
Choice B rationale
Warmth is usually associated with infection or inflammation. A hematoma is a collection of clotted blood outside the blood vessels, not typically characterized by warmth.
Choice C rationale
Redness might be seen in cases of infection or inflammation. A vaginal hematoma is a localized collection of blood and does not inherently cause redness.
Choice D rationale
Pain is a common symptom of a vaginal hematoma due to the pressure and swelling from the accumulated blood.