A nurse is caring for a laboring person who is receiving oxytocin for induction of labor. What is the priority assessment during oxytocin infusion?

Correct Answer: C

Rationale: The correct answer is C because administering IV fluids is crucial during oxytocin infusion to prevent maternal dehydration and maintain fluid balance. This helps prevent complications such as uterine hyperstimulation and fetal distress. Monitoring fetal heart rate continuously (choice A) is important but not the priority. Increasing maternal hydration (choice B) is beneficial but does not address the immediate need for fluid replacement. Assessing uterine tone (choice D) is important but secondary to ensuring adequate hydration.

Correct Answer: A

Rationale: The correct answer is A: administer oxygen. Fetal bradycardia indicates decreased oxygen supply to the fetus, which can lead to fetal distress. Administering oxygen helps improve oxygen levels in the mother's blood, increasing oxygen delivery to the fetus. This intervention is crucial in preventing further complications and ensuring the well-being of the baby. Administering IV fluids (B) and increasing maternal hydration (C) may be beneficial but do not directly address the immediate need for oxygen. Increasing maternal oxygen (D) is redundant since the primary focus should be on fetal oxygenation.

Correct Answer: C

Rationale: The correct answer is C: IUPC (Intrauterine Pressure Catheter). This modality is the only direct and objective measurement of uterine contractions as it provides continuous and precise readings of intrauterine pressure. A: Tocodynamometer measures frequency and duration, but not intensity. B: Fetal spiral electrode monitors fetal heart rate, not uterine contractions. D: Palpation is subjective and not as accurate as IUPC for measuring uterine contractions.

Correct Answer: C

Rationale: The sudden gush of blood and the contracted uterus indicate a separation of the placenta, which is a serious complication called placental abruption. This condition can lead to significant bleeding and jeopardize the health of both the mother and the baby. It is essential for the nurse to recognize this situation promptly and take immediate action to manage the hemorrhage and stabilize the patient. Explanation for incorrect choices: A: Laceration of the genital tract would not typically cause a sudden gush of blood and a contracted uterus. B: The second stage of labor is characterized by the delivery of the baby, not by a sudden gush of blood and a contracted uterus. D: Postpartum hemorrhage could be a consequence of placental separation, but it is not the primary issue indicated by the symptoms described in the scenario.

Correct Answer: C

Rationale: The correct answer is C: Continue to monitor the patient. Early decelerations are benign and occur due to head compression during contractions. They are a normal response to fetal head compression and do not require any intervention as they are self-limiting. Continuing to monitor the patient allows the nurse to observe the pattern of decelerations and ensure they remain early and resolve on their own. Anticipating a cesarean birth (choice A) is unnecessary as early decelerations do not indicate fetal distress. Turning the patient onto the left side (choice B) is typically done for late decelerations, not early decelerations. Notifying the physician or nurse midwife immediately (choice D) is not necessary for early decelerations as they are expected and do not require immediate intervention.