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
Placental abruption is characterized by abdominal pain, vaginal bleeding, and uterine tenderness. It does not cause dyspnea, hypotension, frothy sputum, or loss of consciousness.
Choice B rationale
Uterine rupture typically presents with severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Shock can occur, but not frothy sputum or sudden dyspnea.
Choice C rationale
Uterine inversion leads to pain, hemorrhage, and shock. It does not present with frothy sputum or sudden dyspnea.
Choice D rationale
Anaphylactoid syndrome (amniotic fluid embolism) results from amniotic fluid entering maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, matching the described scenario. .