a nurse is planning care for a client who is receiving oxytocin by continuous iv infusion for labor induction which of the following interventions sho
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HESI Maternity 55 Questions

1. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?

Correct answer: A

Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.

2. Which synthetic hormone is used to prevent miscarriages and can cause masculinization of the fetus?

Correct answer: C

Rationale: Progestin is the synthetic hormone used to prevent miscarriages. While it is beneficial in maintaining pregnancy, in some cases, it can lead to masculinization of the fetus. Testosterone (Choice A) and estrogen (Choice B) are not typically used to prevent miscarriages and do not cause masculinization of the fetus in this context. Oxytocin (Choice D) is a hormone involved in labor and breastfeeding, but it is not used to prevent miscarriages nor does it cause masculinization of the fetus.

3. A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?

Correct answer: D

Rationale: The correct answer is D: Absent patellar reflexes. Absent patellar reflexes can indicate magnesium toxicity, a serious condition that requires immediate intervention to prevent respiratory depression or cardiac arrest. Dizziness while standing (choice A) is common in pregnancy but does not specifically indicate magnesium toxicity. Sinus tachycardia (choice B) can be a normal response to magnesium sulfate but does not indicate toxicity. Lower back pain (choice C) is common in pregnancy and not specifically associated with magnesium toxicity.

4. Do sebaceous glands cause a developing organism to grow arms or wings, skin, or scales?

Correct answer: B

Rationale: The correct answer is B: False. Sebaceous glands are associated with the skin's oil production and have no role in the development of limbs or body coverings. Sebaceous glands primarily produce sebum, an oily substance that lubricates and waterproofs the skin and hair. Choices A, C, and D are incorrect because sebaceous glands do not influence the growth of arms, wings, skin, or scales in a developing organism.

5. Which of the following statements is true of sickle-cell anemia?

Correct answer: C

Rationale: The correct answer is C. Sickle-cell anemia results from a mutation in the beta-globin gene, causing red blood cells to become sickle-shaped. These misshapen cells can obstruct small blood vessels, leading to reduced oxygen delivery to tissues. Choices A, B, and D are incorrect because sickle-cell anemia is typically managed with treatments such as pain relief medications, hydration, and in severe cases, blood transfusions. It is caused by a specific mutation in the beta-globin gene, not by the inability to metabolize phenylalanine. Additionally, sickle-cell anemia is more prevalent in individuals of African, Mediterranean, Middle Eastern, and Indian descent, not exclusive to any specific gender.

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