Health Promotion and Maintenance Q 145

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The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

  

     A. Instruct the client to push

     B. Perform a vaginal exam

     C. Turn off the Pitocin infusion

     D. Place the client in a semi-Fowler’s position

    

    

Correct Answer: C. Turn off the Pitocin infusion

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The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin.

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Option A: Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer A incorrect.

Options B and D: Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation.

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