A woman in active labor is receiving intravenous oxytocin for labor augmentation. What nursing intervention is essential to prevent oxytocin-induced uterine hyperstimulation?

Correct Answer: B

Rationale: When a woman in active labor is receiving intravenous oxytocin for labor augmentation, it is essential to increase the oxytocin infusion rate gradually to prevent oxytocin-induced uterine hyperstimulation. Uterine hyperstimulation can lead to complications such as fetal distress, uterine rupture, and postpartum hemorrhage. By increasing the oxytocin infusion rate gradually, the uterus has more time to adapt to the medication and reduces the risk of hyperstimulation. It is crucial for the healthcare provider to carefully monitor the woman's response to oxytocin and adjust the infusion rate as needed to ensure safe and effective labor augmentation. Monitoring for signs of uterine hyperstimulation, such as persistent contractions close together or excessive uterine activity, is crucial in preventing complications and ensuring the well-being of both the mother and baby.

Correct Answer: A

Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.

Correct Answer: A

Rationale: Assisting the mother into a hands-and-knees position should be prioritized to facilitate fetal rotation and optimize labor progress in the case of persistent occiput posterior fetal position. This position helps in promoting fetal rotation to a more favorable position for delivery by allowing the baby's head to move into the anterior position. It can help alleviate back pain and may help reduce the duration of labor. This simple maneuver can sometimes correct the malposition without the need for interventions like instrumental delivery. It is a non-invasive and effective technique that can be easily implemented by healthcare providers to support the progression of labor.

Correct Answer: B

Rationale: Oxytocin release is responsible for the mild cramping and uterine contractions experienced by the new mother while breastfeeding. When a baby suckles at the breast, it stimulates nerve endings that signal the release of oxytocin from the posterior pituitary gland. Oxytocin is a hormone that plays a crucial role in stimulating the contraction of the uterine muscles, helping the uterus to contract back to its pre-pregnancy size. This process, known as uterine involution, is essential for postpartum recovery and preventing excessive bleeding. Therefore, the new mother's experience of mild cramping and uterine contractions while breastfeeding is a normal physiological response mediated by the release of oxytocin.

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.