The nurse is monitoring a client at 39 weeks' gestation receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Contractions lasting 120 seconds. This finding would prompt the nurse to stop the oxytocin infusion because prolonged contractions can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. It is crucial to maintain an appropriate balance between uterine contractions for labor progress and ensuring fetal well-being during labor induction. Option A) Contractions every 2-3 minutes can be a normal response to oxytocin induction, but it alone does not indicate a need to stop the infusion. Option C) Baseline fetal heart rate of 140 beats/minute is within the normal range for a fetus at term and does not require stopping the infusion. Option D) Client reports mild back pain is a common discomfort during labor and is not a reason to discontinue the oxytocin infusion. Educationally, understanding the potential risks and complications of oxytocin administration during labor induction is essential for nurses caring for laboring women. It is crucial for nurses to recognize abnormal findings and take prompt actions to ensure the safety and well-being of both the mother and the fetus. Continuous monitoring and assessment skills are vital in obstetric care to provide safe and effective care during the labor and delivery process.

Correct Answer: C

Rationale: In this scenario, option C, "True labor contractions increase in intensity and frequency," is the correct answer. This statement indicates understanding because true labor contractions, which signify the onset of active labor, typically become stronger and more frequent over time, leading to cervical dilation and effacement. This progression is crucial for the advancement of labor and eventual delivery of the baby. Option A, "True labor contractions are irregular and stop with rest," is incorrect. True labor contractions are regular, increasing in intensity, duration, and frequency as labor progresses. They do not subside with rest; in fact, they often become more pronounced with activity. Option B, "False labor contractions cause cervical dilation," is incorrect. False labor contractions, also known as Braxton Hicks contractions, do not cause cervical changes or lead to the onset of active labor. They are irregular and do not follow a pattern of increasing intensity and frequency. Option D, "False labor contractions are felt in the back," is also incorrect. While back pain can be a component of both true and false labor contractions for some individuals, it is not a definitive characteristic to differentiate between the two types of contractions. In an educational context, understanding the characteristics of true labor contractions is essential for expectant parents to recognize the signs of labor onset and seek appropriate medical care. Educating prenatal class participants about the progression of labor helps them feel more prepared and confident as they approach childbirth.

Correct Answer: A

Rationale: In this scenario, the nurse's priority action should be to perform a nonstress test (Option A). This test is used to assess fetal well-being by monitoring the fetal heart rate in response to fetal movement. It helps determine if the fetus is receiving an adequate oxygen supply. Performing a nonstress test is crucial because decreased fetal movement could indicate fetal distress or compromise, which requires immediate attention to prevent adverse outcomes. This test provides real-time information on fetal status, guiding further interventions or decisions. Encouraging the client to drink orange juice (Option B) is not the priority action in this situation. While maternal hydration or consuming something sweet may sometimes encourage fetal movement, in cases of decreased fetal movement at 36 weeks, a more formal assessment like a nonstress test is needed to evaluate fetal well-being accurately. Scheduling an ultrasound (Option C) can provide detailed information about fetal status but may not be as immediate or readily available as a nonstress test in determining the current fetal response to stimuli. In cases of decreased fetal movement, time is critical, and the nonstress test offers a quicker assessment of fetal well-being. Notifying the healthcare provider (Option D) is important but should come after initiating the nonstress test. The provider should be informed of the situation and the test results, but the priority is to first assess the fetal well-being through the nonstress test. In the context of maternal newborn care, understanding the significance of fetal movement assessment and the appropriate interventions is vital for ensuring the health and safety of both the mother and the baby. Nurses need to prioritize prompt and accurate assessments to provide timely interventions and prevent potential complications during pregnancy.

Correct Answer: B

Rationale: In the context of preterm labor, it is crucial for the nurse to educate the client about the warning signs that require immediate attention. Lower back pain and cramping (Option B) are concerning symptoms that could indicate preterm labor. These symptoms may signal the onset of contractions and cervical changes that could lead to premature delivery. It is essential for the client to report this symptom promptly to their healthcare provider to receive timely intervention and prevent preterm birth complications. The other options are not indicative of immediate concern for preterm labor. Frequent urination (Option A) is a common symptom during pregnancy due to hormonal changes and the growing uterus pressing on the bladder. Increased appetite (Option C) is also a typical occurrence in pregnancy and does not signal a potential issue with preterm labor. Braxton Hicks contractions (Option D) are usually irregular and do not cause cervical changes leading to preterm labor. Educationally, it is important for nurses to emphasize the significance of recognizing and reporting warning signs of preterm labor to ensure the best possible outcomes for both the mother and the baby. Providing clear information about what symptoms require immediate attention empowers the client to take proactive steps in their prenatal care and seek appropriate medical assistance when needed.

Correct Answer: B

Rationale: The correct answer is B) To assess the baby’s growth and development. An anatomy ultrasound at 20 weeks' gestation is typically performed to evaluate the baby's growth, development, and overall anatomy. This detailed scan allows healthcare providers to assess the baby's organs, limbs, spine, brain, and other structures to ensure they are developing properly. It also helps in detecting any potential abnormalities that may require further evaluation or intervention. Option A) To confirm the baby’s sex is incorrect because while an ultrasound may reveal the baby's sex, its primary purpose at 20 weeks is to assess development, not determine gender. Option C) To detect early signs of labor is incorrect as an anatomy ultrasound does not typically provide information about the onset of labor. Signs of labor are usually monitored through other assessments closer to the due date. Option D) To evaluate amniotic fluid levels is incorrect because amniotic fluid levels are typically assessed through a separate ultrasound called an amniotic fluid index, which is not the primary purpose of an anatomy ultrasound at 20 weeks. In an educational context, it is important for nurses to understand the various types of ultrasounds performed during pregnancy and their specific purposes. This knowledge allows nurses to effectively educate and support pregnant clients in understanding the importance of these screenings for the health and well-being of both the mother and the baby.