RNSG 2363 - ATI Reproduction Labor Quiz. Questions & Answers.
1. A nurse on the labor and delivery unit is caring for a patient who is having induction
... [Show More] of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 secs., and are strong to palpitations. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and return to baseline after contraction is over. Which of the following actions should the nurse take?
a. Decrease the rate of infusion of the maintenance IV solution
b. Discontinue the infusion of the IV oxytocin
Discontinue the oxytocin infusion immediately if the client is experiencing late decelerations due to uterine hyperstimulation.
c. Increase the rate of infusion of the IV oxytocin
d. Slow the client’s rate of breathing
2. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
a. Encourage the client to perform Kegel exercises
b. Encourage the client to move to the left lateral position
c. Ask the client to rate her pain
d. Assist the client to the bathroom to void
A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.
3. A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical
cord protruding from the vagina. Which of the following actions should the nurse perform first?
a. Cover the cord with a sterile, moist saline dressing
b. Prepare the client for an immediate birth
c. Place the client in knee-chest position
d. Insert a gloved hand into the vagina to relieve pressure on the cord
This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation to the fetus.
4. A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of
observation, the nurse notes the following findings: The fetal heart baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15/min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make?
a. A negative test
b. A nonreactive test
An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15/min above the FHR baseline and last at least 15 seconds.
c. A positive test
d. A reactive test [Show Less]