Unit 2: High-risk Intrapartum 1/5
A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion?
Change in the fetal heart rate from 128 to 102 bpm
A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client?
Diarrhea and back pain
There are four clients in the labor suite. Each client's labor is being augmented with oxytocin (Pitocin). Which of the women should the nurse monitor carefully for the potential of uterine rupture?
Age 25, G4P3003, last delivery by cesarean section
A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time?
Assess the fluid with nitrazine and see if the paper turns blue
A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse to make at this time?
"Have you felt the baby move since the membranes broke?"
A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus (HPV). Which of the following actions by the nurse is appropriate?
Follow standard infectious disease precautions
The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order?
Primagravida with a transverse lie
A woman, 40 2 / 7 weeks' gestation, has had ruptured membranes for 15 hours with no labor contractions. Her obstetrician has ordered 10 units of oxytocin (Pitocin) to be diluted in 1,000 mL Ringer's lactate. The order reads: Administer oxytocin IV at 0.5 milliunit per min. Calculate the drip rate for the infusion pump to be programmed. Calculate to the nearest whole number.
3 mL/hr
A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time?
Vaginal examination
A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see?
Confusion, drowsiness, and vomiting
A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes?
Endocervically
A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following fi ndings would warrant the removal of the prostaglandin?
Contraction frequency of 1 minute
The nurse turns off the oxytocin (Pitocin) infusion after a period of tachysystole. Which of the following outcomes indicates that the nurse's action was effective?
Frequency every 3 minutes
The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take?
Increase the intravenous infusion rate
A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fl uid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time?
Maternal temperature
A primigravid client received Cervidil (dinoprostone) for induction 8 hours ago. The Bishop score is now 10. Which of the following actions by the nurse is appropriate?
Monitor for onset of labor
A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/ min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time?
Monitor the client's labor
The physician has ordered Prepidil (dinoprostone) for four gravidas at term. The nurse should question the order for which of the women?
Multigravida with late decelerations
A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time?
Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth
A client, G3 P2002, 40 weeks' gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman?
The baby may develop thrush after delivery
An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunit per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunit per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action?
The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug.
A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by signifi cant fetal heart bradycardia. Which of the following interventions should the nurse perform fi rst?
Turn off the oxytocin infusion
Four women request to labor in the hospital bathtub. In which of the following situations is the procedure contraindicated? Select all that apply.
Woman receiving oxytocin for induction Woman with meconium-stained fluid
