Quiz and Test Bank (500+
Questions)
1. Question
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to
stimulate uterine contractions. Which assessment finding would indicate to
the nurse that the infusion needs to be discontinued?
A. Three contractions occurring within a 10-minute period
B. Increased urinary output
C. Adequate resting tone of the uterus palpated between contractions
D. A fetal heart rate of 90 beats per minute
Incorrect
Correct Answer: D. A fetal heart rate of 90 beats per minute
A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable
decelerations indicate fetal distress and the need to discontinue Pitocin.
The
, Option A: Pitocin (oxytocin injection) is a natural hormone
that causes the uterus to contract used to induce labor,
strengthen labor contractions during childbirth, control bleeding
after childbirth, or induce an abortion. Option B: Oxytocin has
an antidiuretic effect and increases the urinary excretion of
AQP2 in humans whose urinary concentration mechanism is
preserved. Urine volume and free water clearance were
decreased, and urine osmolality was increased by the
administration of oxytocin or dDAVP in the normal volunteers
and CDI patients.
Option C: In a normal labor, one contraction every two to three
minutes or less than five contractions in a 10 minute period is
ideal. A uterus must rest between contractions, having sufficient
uterine resting tone (soft to the touch), and uterine resting time
(about one minute).
2. Question
A nurse is beginning to care for a client in labor. The physician has prescribed
an IV infusion of Pitocin. The nurse ensures that which of the following is
implemented before initiating the infusion?
A. Placing the client on complete bed rest
B. Continuous electronic fetal monitoring
C. An IV infusion of antibiotics
D. Placing a code cart at the client’s bedside
Incorrect
Correct Answer: B. Continuous electronic fetal monitoring
, for a minimum of 20 minutes before starting oxytocin and should be
continued until the baby is delivered.
Option A: Complete bed rest is not a necessity before initiating
Pitocin infusion. Pitocin is indicated for the initiation or
improvement of uterine contractions, where this is desirable and
considered suitable for reasons of fetal or maternal concern, in
order to achieve vaginal delivery.
Option C: It is unnecessary to administer IV antibiotics before
Pitocin infusion. Immediately administer broad-spectrum
antibiotics only to patients with severe postabortion infection.
Option D: A code cart may be placed beside the client but in
case of overdose, contact the Poison Control Center.
3. Question
A nurse is monitoring a client in active labor and notes that the client is
having contractions every 3 minutes that last 45 seconds. The nurse notes
that the fetal heart rate between contractions is 100 BPM. Which of the
following nursing actions is most appropriate?
A. Encourage the client’s coach to continue to encourage
breathing exercises.
B. Encourage the client to continue pushing with each contraction.
C. Continue monitoring the fetal heart rate.
D. Notify the physician or nurse-midwife.
Incorrect
, management, and the physician or nurse-midwife needs to be notified.
Option A: Steps can be taken to help the fetus get more
oxygen, such as having the mother change position. If these
procedures do not work, or if further test results suggest the
fetus has a problem, the ob-gyn or other health care
professional may decide to deliver right away.
Option B: Uterine contractions also may be monitored with a
special tube called an intrauterine pressure catheter that is
inserted through the vagina into the uterus. Internal
monitoring can be used only after the membranes of the
amniotic sac have ruptured.
Option C: Fetal heart rate monitoring may help detect changes
in the normal heart rate pattern during labor. If certain changes
are detected, steps can be taken to help treat the underlying
problem. Fetal heart rate monitoring also can help prevent
treatments that are not needed.
4. Question
A nurse is caring for a client in labor and is monitoring the fetal heart rate
patterns. The nurse notes the presence of episodic accelerations on the
electronic fetal monitor tracing. Which of the following actions is most
appropriate?
A. Document the findings and tell the mother that the monitor
indicates fetal well-being.
B. Take the mother’s vital signs and tell the mother that bed rest
is required to conserve oxygen.
C. Notify the physician or nurse-midwife of the findings.
D. Reposition the mother and check the monitor for changes in
the fetal tracing.