The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record?

Correct Answer: C

Rationale: The correct answer is C. Including test results ensuring that the fluid is not urine in the patient's record is crucial after a spontaneous rupture of membranes to confirm the presence of amniotic fluid, indicating the onset of labor. This information helps in assessing the progress of labor and ensuring the safety of both the mother and the fetus. A: Fetal heart rate is important but not directly related to the spontaneous rupture of membranes. It should be monitored separately. B: Pain level is subjective and can vary among individuals, not directly related to the rupture of membranes. D: The patient's understanding of the event is important for communication but does not provide essential clinical information related to the rupture of membranes.

Correct Answer: D

Rationale: Rationale: 1. Past 42 weeks of gestation increases the risk of stillbirth. 2. Oxytocin can help initiate labor to reduce the risk. 3. Induction at this stage is considered safe and beneficial. 4. Other choices are not direct indications for oxytocin induction and may have different management strategies. Summary: - A: Multiple fetuses and polyhydramnios may require different approaches. - B: History of long labors may not necessarily indicate the need for oxytocin induction.

Correct Answer: A

Rationale: The correct answer is A because a patient in transition with contractions every 2 minutes lasting 90 seconds each is experiencing very intense and frequent contractions, indicating high uterine activity. Discontinuing oxytocin infusion is crucial in this scenario to prevent hyperstimulation, which can lead to fetal distress or uterine rupture. Choice B is incorrect because the patient is in early labor and the contractions are less frequent and less intense compared to the correct answer. Choice C is incorrect as the patient in active labor with contractions every 3 minutes lasting 60 seconds each is not as intense as the patient in transition in the correct answer. Choice D is incorrect because although the contractions are frequent and lasting longer, the intensity described in choice A is more concerning and requires immediate discontinuation of oxytocin infusion.

Correct Answer: C

Rationale: The correct answer is C: Persistent fetal bradycardia below 100 bpm. This is crucial because it indicates fetal distress and requires immediate intervention to prevent potential harm to the baby. Bradycardia below 100 bpm may indicate inadequate oxygen supply to the fetus, necessitating urgent action. Maternal vital signs in choices A and B are within normal ranges. Choice D, decreased intensity of uterine contractions, while important, is not as critical as fetal bradycardia in this scenario.

Correct Answer: A

Rationale: The correct answer is A because the priority intervention for a patient receiving oxytocin infusion for labor augmentation is to monitor fetal heart rate and uterine contractions. This is essential to ensure the safety of both the mother and the baby. Increasing the rate of Pitocin infusion (B) can lead to hyperstimulation and fetal distress. Providing oxygen and changing position (C) may be helpful in some situations but are not the priority. Stopping the Pitocin infusion (D) should only be done if there are signs of fetal distress or other complications.