Exam (elaborations)
NUR404 Exam 4 Questions And Accurate Answers Graded A+
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NUR404 Exam 4 Questions And Accurate Answers Graded A+A multipara client in labor is contracting every 2 minutes but never over 50 mm Hg in
intensity; resting uterine tone is elevated at 20 to 25 mm Hg. She asks what she can do
to help the contractions become more productive. The nurse's optimal response is:
A. Between contractions, rest.
B. Request oxytocin to augment contractions.
C. Be patient and let the contractions strengthen on their own.
D. walk to establish regular contractions. - Answer A
The client's contractions are hypertonic because of the high resting tone. Hypertonic
contractions are caused by overstimulation or erratic stimulation of the uterus. Rest, not
activity, is helpful in allowing contractions to become more productive. Oxytocin is
contraindicated. There is no assurance that time will change the status of the
contractions.
This is a pregnant woman in labor who has dilated to 8 cm. Suddenly, the heat rate
drops. The nurse examines her perineum and finds that the fetal cord has prolapsed.
The first action the nurse would perform would be to:
A. Turn her to her left side
B. Place her in a knee-chest position
C. Replace the cord with gentle pressure
D. Cover the exposed cord with a dry, sterile wrap - Answer B
Keeping the pressure of the fetus off the cord improves fetal circulation. Placing the
woman in a knee-chest position accomplishes this. Replacing the cord could knot it;
allowing it to dry would constrict cord blood vessels.
,A woman is going to have labor induced with oxytocin. Which statement reflects the
induction technique the nurse expects the primary care provider to order?
A. Administer oxytocin in a 20 cc bolus of saline.
B. Administer oxytocin in two divided intramuscular sites.
C. Administer oxytocin diluted in the main intravenous fluid.
D. Administer oxytocin diluted as a "piggyback" infusion. - Answer D
Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be
halted quickly if overstimulation of the uterus occurs.
After an hour of oxytocin therapy, a woman in labor states that she feels dizzy and
nauseated. The best nursing action would be to:
A. Check the rate of flow of the oxytocin infusion.
B. Offer oral orange juice for extra potassium.
C. Perform a vaginal exam for full dilation (dilatation).
D. Tell her to breathe in and out rapidly. - Answer A
A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and
nausea. Symptoms are relieved by assessing and slowing the infusion rate.
For questions 1-2, refer to the scenario below.
A woman is in the hospital only 15 minutes when she begins to give birth precipitously.
The fetal head begins to emerge as the nurse walks into the labor room. The nurse's
best action would be to:
A. place a hand gently on the fetal head to guide birth.
B. ask her to push with the next contraction so birth is rapid.
C. assess blood pressure and pulse to detect placental bleeding.
,D. attach a fetal monitor to determine fetal status. - Answer A
If a head is controlled as it emerges, trauma to internal vessels or to the maternal cervix
is less apt to occur.
A woman is delivering the placenta when she suddenly experiences an amniotic fluid
embolism. The nurse's initial response would be to:
A. administer oxygen by mask.
B. increase her intravenous fluid infusion rate.
C. apply firm pressure to the fundus of her uterus.
D. instruct the woman to breathe shallow, punctuated breaths. - Answer A
An amniotic embolism quickly becomes a pulmonary embolism. The woman needs
oxygen to compensate for the sudden obstruction of blood passage through her lungs.
What would be the best approach to take with a woman whose labor is dysfunctional
during the first stage of labor?
A. Conserve the woman's energy by not explaining anything until after the birth has
taken place.
B. Limit discussion to those things about which the woman specifically asks questions.
C. Keep the woman informed about what is happening.
D. Instruct her not to feel anxious or discouraged about what is happening. - C
Any dysfunction in labor is frustrating to women. At least keeping open lines of
communication keeps the woman well informed about what is happening.
, Labor client A pregnant client in labor is having contractions about 4 minutes apart but
seldom higher than 20 mm Hg in intensity with a resting tone from 5 to 8 mm Hg. The
client asks what can be done to make contractions more effective. What is the nurse's
response to the client?
A. "Rest, because the contractions are hypertonic."
B. "You may need oxytocin to strengthen contractions."
C. "Don't worry because contractions of this type will build up of their own accord."
D. "See if you can sit up a bit straighter and make the contractions more regular." -
Answer B
The client is experiencing hypotonic contractions, which are often helped by
administering oxytocin. These contractions may, or may not, start to strengthen on their
own. Also, the therapist is instructing the client to relax, which does not address the
client's concern. Rest would be indicated when there are hypertonic contractions.
Sitting up will not facilitate the contractions becoming more regular.
A pregnant client is ordered to induce labor with oxytocin. The nurse is planning to
administer the medication. Which action is appropriate?
A. Prepare a syringe with a bolus dose of medication.
B. Administer the initial dose as an intramuscular injection.
C. Use a port closest to the client for the oxytocin infusion.
D. Add the oxytocin to the prescribed Ringer's lactate main infusion. - Answer C
When oxytocin is administered, the infusion should be "piggybacked" to a maintenance
IV solution and add the piggyback to the main infusion at the port closest to the client.
This way, during the induction of labor or augmentation of labor, one can easily stop the
oxytocin by simply clamping off the oxytocin tubingsolution will still be in the tubing to
continue to infuse, and the main IV line can still be maintained. It is not given as an
intravenous bolus or an initial intramuscular injection. Oxytocin is not diluted in the
principal intravenous fluid.
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