Author Question: A nurse assessing a woman in labor notes late decelerations on the fetal monitor and documents ... (Read 38 times)

dalyningkenk · **on:** Jun 28, 2018

A nurse assessing a woman in labor notes late decelerations on the fetal monitor and documents contractions occurring every 1 to 2 minutes. Oxytocin (Pitocin) is being infused IV, and oxygen is being delivered at 8 L/min per mask. The woman is positioned

A.
Discontinue the oxygen.
B.
Increase the oxytocin rate.
C.
Assist the woman to a supine position.
D.
Stop the oxytocin infusion.

Question 2

A new nurse is preparing to assess the fetal heart rate response to stimulation with vibroacoustic stimulation. What action by the new nurse would prompt the precepting nurse to intervene?

A.
Nurse attempts stimulation in the presence of fetal bradycardia.
B.
Nurse attempts stimulation in the presence of ruptured membranes.
C.
Nurse places stimulation device over the fetal head for 1 to 2 seconds.
D.
Nurse waits until fetal heart rate is at baseline before initiating the stimulation.

Animal_Goddess · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
Late decelerations are a sign of uteroplacental insufficiency and are often indicative of hypoxia and metabolic acidemia. Contractions that occur this frequently signify uterine hyperstimulation. Both circumstances indicate that the oxytocin should be stopped immediately. Discontinuing the oxygen and increasing the oxytocin infusion are both contraindicated. Placing the woman in a supine position can lead to maternal hypotension, worsening this situation.

Answer to Question 2

ANS: A
Fetal stimulation should occur when the fetal heart rate is at baseline, and not in the presence of decelerations or bradycardia. If the nurse attempts to stimulate the fetal heart rate in a bradycardic fetus, the preceptor should intervene. The other options are correct steps in the procedure (stimulation can occur in the presence or absence of ruptured membranes).