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 C
Explanation
Choice A rationale
Dexamethasone does not directly stop labor contractions; instead, it is used to enhance fetal lung maturity.
Choice B rationale
Dexamethasone is not for infection prevention; antibiotics are used for that purpose in cases of premature rupture of membranes.
Choice C rationale
Dexamethasone is administered to enhance fetal lung maturity, reducing the risk of respiratory distress syndrome in preterm infants.
Choice D rationale
Dexamethasone is not used for pain relief in preterm labor; other medications are prescribed for pain management.
Correct Answer is C
Explanation
Choice A rationale
While maternal lacerations are a risk during childbirth, they are not the greatest risk in cases of fetal dystocia. The focus is primarily on fetal wellbeing.
Choice B rationale
Fetal injury such as bruising can occur with dystocia, but the primary concern is the potential for severe, life-threatening complications.
Choice C rationale
Neonatal asphyxia related to prolonged labor is the greatest risk with fetal dystocia. Prolonged labor can lead to decreased oxygen supply to the fetus, causing asphyxia and
potential brain injury.
Choice D rationale
Increased consideration for a cesarean delivery is a possible outcome of fetal dystocia, but it is a management decision rather than a direct risk to the baby’s immediate health.