1. Nurse Julia is aware that Labor is divided into how many stages? Show 2. Pen, a nurse-midwife determines that a client is in the second stage of labor and may start pushing. What marks the beginning of the second stage, and what marks
the end? 3. Jannah, who is in labor receives epidural anesthesia. The nurse should assess carefully for which adverse reaction to the anesthetic agent? 4. Nurse Venice is aware that one of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor? 5. Nurse Olive asseses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include: 6. To promote comfort during labor, Nurse Michelle advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia? 7. After delivering a neonate, a client delivers the placenta. At this time, where does nurse Adam expect to palpate the uterine fundus? 8. During the active phase of the first stage of labor, Maricris undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority? 9. A client with active genital herpes is admitted to the labor and delivery area during the first stage of labor. Which type of birth should nurse Roy anticipate for this client? 10. After a client enters the second stage of labor,
nurse Blessy notes that her amniotic fluid is port-wine colored. What does this finding suggest? 11. Clariz arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back
discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? 12. A client in labor tells April that she feels a strong urge to push. Physical examination
reveals that her cervix is not completely dilated. The nurse-midwife tells her not to push yet. What is the rationale for this instruction? 13. An assisted birth using
forceps or a vacuum extractor may be performed for ineffective pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. Nurse Sally is caring for the mother following an assisted birth should keep which of the following in mind? 14. Nurse Divina is aware that the following would be an inappropriate indication of placental detachment? 15. When reviewing a fetal monitor strip, nurse Roy looks for reassuring and nonreassuring fetal heart rate (FHR) patterns. Which pattern is nonreassuring? 16. Nurse Adrian is aware that an expected fetal adverse reaction to meperidine (Demerol) during labor is: 17. During labor, Amy greatly relies on her husband for support. They previously attended childbirth education classes, and now
he’s working with her on comfort measures. Which nursing diagnosis would be appropriate for this couple? 18. Late in the first
stage of labor, Olivia receives a spinal block to relieve discomfort. A short time later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What do the client’s symptoms suggest? 19. Denice with intrauterine growth retardation is admitted to
the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her plan of care? 20. Lou is in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn’t attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time? 21. Which of the following physiologic changes during labor makes it necessary for nurse Hazel to assess blood pressure frequently? 22. During the fourth stage of labor, Jessica should be assessed carefully for: 23. Several
minutes after a vaginal delivery, nursing assessment reveals blood gushing from the client’s vagina, umbilical cord lengthening, and a globular-shaped uterus. Nurse Luz should suspect which condition? 24. Nurse Mariane is caring for a client who’s in labor. The physician still isn’t
present. After the baby’s head is delivered, which nursing intervention would be most appropriate? 25. Vicky, who is in labor shouts to the nurse, “My baby is coming right now! I
feel like I have to push!” An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate? Answers and Rationale More nclex questions Passing the nclex exam Which of the following is the most serious adverse effect associated with oxytocin administration during labor?Foetal distress and foetal death: Administration of oxytocin at excessive doses results in uterine overstimulation which may cause foetal distress, asphyxia and death, or may lead to hypertonicity, tetanic contractions or rupture of the uterus.
Does oxytocin cause fetal hypoxia?Oxytocin itself has no adverse effect on the fetus, but it will produce uterine contraction after use. Excessive uterine contraction may lead to abnormal blood supply of the fetal placenta and fetal hypoxia.
Which adverse effect would the nurse assess for after administering oxytocin to a client to stimulate labor?The main adverse effects of oxytocin are related to uterine hyperstimulation, where there's too much contraction. This could cause painful contractions, and lead to uterine rupture and hemorrhage. It could even restrict placental blood flow, resulting in abnormal fetal heart rate patterns.
How does oxytocin cause fetal distress?Interventions with oxytocin, particularly at high doses, may have potential adverse effects on the mother and the fetus, such as uterine tachysystole and impairment of fetal heart rates 3 . This occurs due to the reduction or interruption of the blood flow to the intervillous space during contractions 7 .
|
Which of the following is the most serious adverse effect associated with oxytocin?
zusammenhängende Posts
Urheberrechte © © 2024 ketiadaan Inc.
