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1. A nurse is caring for a client who is in the latent phase of labor and is receiving
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xz oxytocin via continuous IV infusion.The nurse notes that the client is having
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xz contractions every 2 min which last 100-110 seconds that the fetal heart rate is
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xz reassuring. What action should the nurse take?
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a. decrease the dose of oxytocin by half
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b. administer oxygen via nonrebreather mask xz xz xz xz
c. decrease the infusion rate of the maintenance IV fluid
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d. administer terbutaline 0.25mg subq xz xz xz
Answer>> a.decrease the dose of oxytocin by half
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Rationale: The nurse should decrease the dose of oxytocin by half because the client is
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,experiencing uterine tachysystole. xz xz
2. A nurse is caring for a client who is in active labor and has meconium staining of the
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xz amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor.
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xz What action should the nurse take?
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a. prepare the client for emergency c-section
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b. perform endotrach suctioning as soon as the fetal head is delivered
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c. prepare equipment needed for newborn resuscitation
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d. prepare the client for an ultrasound exam
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Answer>> c.prepare equipment needed for newborn resuscitation
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Rationale: The nurse should ensure that all supplies and equipment needed for
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resuscitation of the newborn are readily available for every delivery. Endotracheal
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xz suctioning
is recommended in cases of meconium staining only if the newborn has poor respiratory
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xz effort, decreased muscle tone, and bradycardia after delivery.
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, 3. A nurse is reviewing the medical record of a client who is at 33 wks gestation and
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xz has placenta previa and bleeding.What scripts should the nurse clarify with the provider?
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a. insert a large-bore IV catheter xz xz xz xz
b. perform a vaginal exam xz xz xz
c. perform continuous external fetal monitoring xz xz xz xz
d. obtain a blood sample for lab testing xz xz xz xz xz xz
xz Answer>> b. perform a vaginal exam x z xz xz xz xz
Rationale: When a client has a placenta previa, the placenta implants in the lower part of
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the uterus and obstructs the cervical os (the opening to the vagina).The nurse should
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xz clarify this prescription because any manipulation can cause tearing of the placenta and
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xz increased bleeding. xz