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
Reduction of fever is not a primary effect of carboprost tromethamine. This medication is primarily used to induce uterine contractions to manage postpartum hemorrhage.
Choice B rationale
While maintaining stable blood pressure is important, it is not the specific indicator of carboprost tromethamine's effectiveness. This medication is used to control bleeding.
Choice C rationale
Increased comfort, although significant, is not the direct effect of carboprost tromethamine. The primary aim is to induce uterine contractions to manage hemorrhage.
Choice D rationale
Decreased lochia rubra indicates the reduction of postpartum bleeding, which is the primary purpose of administering carboprost tromethamine. This outcome shows the medication is effective.
Correct Answer is D
Explanation
Choice A rationale
A low transverse uterine scar is considered the safest type of uterine incision for a VBAC because it is less likely to rupture compared to other types of scars. Therefore, a low transverse uterine scar would not disqualify the patient for VBAC.
Choice B rationale
Patient asking multiple questions does not disqualify her for VBAC. Patient education and ensuring the patient’s understanding and agreement with the procedure is an essential part of the process.
Choice C rationale
Induction of labor in the first pregnancy does not automatically disqualify a patient from attempting VBAC. The success of VBAC depends on multiple factors including the reason for the initial cesarean section.
Choice D rationale
A cesarean due to pelvic abnormalities would disqualify the patient for VBAC because the underlying pelvic condition that necessitated the initial cesarean section is likely still present and would increase the risk of complications during vaginal birth.