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 D
Explanation
Choice A rationale
Oxytocin is used to induce or augment labor, not typically used before an external version, which is a procedure to turn a breech baby to a head-down position.
Choice B rationale
Methylergonovine is used to prevent or control postpartum hemorrhage by inducing strong uterine contractions, not indicated before an external version.
Choice C rationale
Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not required for an external version.
Choice D rationale
Terbutaline is a tocolytic agent used to relax the uterus, making it easier to manipulate the fetus during the external version procedure.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Petechiae, small red or purple spots on the skin, indicate a low platelet count, which is a component of HELLP syndrome.
Choice B rationale
Jaundice, a yellowing of the skin and eyes, suggests liver involvement and hemolysis, both of which are features of HELLP syndrome.
Choice C rationale
4+ deep tendon reflexes are associated with severe pre-eclampsia but are not specific to HELLP syndrome.
Choice D rationale
3+ pitting edema, severe fluid retention causing swelling, can be a sign of HELLP syndrome, indicating liver or kidney involvement. .