Elevate Module 3
The nurse is to administer oxytocin 0.5 milliunits/min IV to a client admitted for labor induction. Oxytocin is available as 10 units/1000 ml 0.9% normal saline. How many mL/hour of the oxytocin should be administered? 1. 3 mL/hour 2. 6 mL/hour 3. 10 mL/hour 4. 12 mL/hour
1 Rationale 1. Correct: 3 mL/hour will deliver oxytocin 0.5 milliunits/min. Calculations for IV Oxytocin Solution NOTE 1 Unit = 1,000 milliunits TO MAKE SINGLE-STRENGTH IV SOLUTION: Add 10 Units of Oxytocin to 1 liter of compatible IV fluid. TO INFUSE: Convert prescribed milliunits/min to mL/hr and set infusion pump. AMOUNT PRESCRIBED: 0.5 milliunits/min CALCULATIONS: 10 Units/1 L = 10,000 milliunits/1,000 mL OR 10 milliunits/1 mL. 10 milliunits/1 mL = 0.5 milliunits/X mL Cross-multiply to get: 0.5 = 10X X = 0.05, so 0.05 mL/min Multiply by 60 minutes to get amount infused per hour. THINK: 0.05 milliunits = 0.05 mL/min 0.05 mL/min x? 60 min/hr = 3 mL/hr (0.05 x ?60 = 3) Set the infusion pump for 3 mL/hr.
A client at 28 weeks gestation reports swollen hands and feet during her prenatal visit. Which additional signs/symptoms would be of concern to the nurse? 1. Decreased deep tendon reflexes 2. Proteinuria 3. One week weight gain of 1 pound (2.2 kg). 4. Muscle weakness 5. Light sensitivity
1, 2, 5 Rationale 1., 2., & 5 Correct: The deep tendon reflexes will be increased (hyperactive) with preeclampsia. Proteinuria, another sign of preeclampsia, is the result of proteins, normally confined to the blood by the filtering role of your kidney, spilling into your urine. This is because preeclampsia temporarily damages this "filter." Albumin, as well as many other proteins, are lost this way. Vision changes are one of the most serious symptoms of preeclampsia. They may be associated with central nervous system irritation or be an indication of swelling of the brain (cerebral edema). Common vision changes include sensations of flashing lights, auras, light sensitivity, or blurry vision or spots. This client is going into preeclampsia. 3. Incorrect: Weight gain of more than 3-5 pounds in a week may be an indicator of preeclampsia. Damaged blood vessels allow more water to leak into and stay in your body's tissue and not to pass through the kidneys to be excreted. 4. Incorrect: Muscle spasms, rather than weakness will occur. This indicates nerve/muscle irritation.
A client who delivered a 9 pound 12 ounce (4.17 kg) baby 1 hour ago, has saturated 2 peri-pads in 15 minutes. Which nursing actions should the nurse take? 1. Assess fundal height and tone. 2. Have client void. 3. Massage the fundus. 4. Begin an infusion of oxytocin. 5. Obtain pulse rate and BP and compare with baseline.
1, 2, 3, 5 Rationale 1., 2., 3., & 5. Correct: Fundal height is measured in centimeters (or fingerbreadths) in relation to the umbilicus. It is used to assess the rate of uterine involution. The usual progression of uterine descent into the pelvis is 1 cm (about one fingerbreadth) a day. After delivery (especially when an oxytocin drug is administered after the expulsion of the placenta), the fundus of the uterus is firm and may be approximately at the level of the umbilicus or just below. The uterus is contracted to the size of a large grapefruit. By 10 days' postpartum, it should not be abdominally palpable. A full (distended) bladder can push the uterus up and cause it to deviate to one side (usually the right side) and interfere with involution. If blood clots collect within the uterus, contractions stop, and the fundus of the uterus may rise and feel soft or boggy. This atony results in increased bleeding. Massage may be needed. A uterus deviating from the midline usually requires emptying of the bladder in order for involution to continue. A boggy fundus needs to be massaged to firm it back up. The pulse rate and B/P compared with baseline may give indication of possible complication excessive blood loss. 4. Incorrect: The most common reason for saturating 2 peri-pads is a boggy fundus. The priority is to massage the fundus and stop the bleeding! If post-partum hemorrhage continues, an infusion of oxytocin may be initiated.
In which client should the nurse initiate a prescription for a contraction stress test? 1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 3. Client at 38 weeks with gestational diabetes. 4. Client at 37 weeks gestation. 5. Client with placenta previa. 6. Client with preterm membrane rupture
3, 4 Rationale 3., & 4. Correct: There is no reason to suspect complications from a contraction stress test for these clients. The nurse should proceed with the test. 1. Incorrect: 6 weeks is too early to stimulate contractions. This could lead to a preterm delivery. 2. Incorrect: Stimulating contractions in a client with previous cesarean deliveries is not recommended. This may lead to uterine rupture. 5. Incorrect: Stimulating contractions in a client with placenta previa is not recommended. This may lead to hemorrhage. 6. Incorrect: Conditions such as preterm membrane rupture may increase risk of preterm labor and delivery.
A client has been admitted with advanced Cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs.(2.71 kg) since yesterday's measurements. What further assessment findings would the nurse expect? 1. Hypotension 2. Cool extremities 3. Bradycardia 4. CVP reading of 8 mm/Hg 5. Radial pulses 4+/4+
1, 2 Rationale 1. & 2. Correct: These are signs and symptoms of FVD due to 3rd spacing and shock is what you are afraid of. 3. Incorrect: We would expect the heart rate to increase in FVD in an effort to move what little volume you have left through the system. 4. Incorrect: This is a high CVP, and with FVD you would expect it to be low. 5. Incorrect: Pulses are evaluated on a 4 point scale, so 4 would be a bounding pulse which would indicate fluid volume excess.
The nurse recognizes that Rho(D) immune globulin would be indicated for which Rh negative client? 1. Miscarriage at 12 weeks gestation 2. Abdominal trauma 3. Undergoes chorionic villus sampling (CVS) 4. Diagnosed with an ectopic pregnancy 5. Seventy-two hours post delivery of term Rh negative baby 6. Twenty-eight weeks gestation
1, 2, 3, 4, 6 Rationale 1., 2., 3., 4, 6. Correct: All of these clients may need to receive the Rho(D) immune globulin because they could have some bleeding and therefore develop antibodies against a Rh positive fetus. An optional Rho(D) immune globulin dose may have been given during pregnancy by the practitioner at 28 weeks. 5. Incorrect: An Rh negative newborn does not need the Rho(D) immune globulin because the Rh negative mom does not have antibodies against the Rh factor.
A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? You answered this question Incorrectly 1. Alternating pressure mattress 2. Bath chair 3. Mechanical hoist lift 4. Oxygen 5. Suction equipment 6. Hospital bed
1, 4, 5, 6 Rationale 1., 4., 5., & 6 Correct: An alternating pressure mattress will help to prevent pressure ulcers. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. The client with hepatic encephalopathy is unresponsive and may need suctioning if unable to clear secretions from the oropharynx. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. 2. Incorrect: The unresponsive client will not need a bath chair. This client will receive a bed bath. 3. Incorrect: Mechanical hoist lifts are expensive and require special training to use.
Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the nurse takes priority? 1. Elevate the head of the bed 2. Administer oxygen by face mask 3. Position client side-lying 4. Begin dopamine 5 mcg/kg/min
3 Rationale 3. Correct: When you turn them on their side, this relieves pressure on the vena cava and the BP will go UP. 1. Incorrect: This will drop the pressure more. 2. Incorrect: O2 doesn't bring up the BP. 4. Incorrect: Stay away from drugs as long as you can.
An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? 1. When sitting, keep knees slightly lower than the hips. 2. Bend at the waist with legs straight and knees locked. 3. Squarely face the direction of anticipated movement. 4. Pivot to turn while holding an object. 5. Wear comfortable, low-heeled shoes. 6. When lifting an object, hold it away from your body.
3, 4, 5 Rationale 3., 4., & 5. Correct: Flexion of the spine with the legs straight (toe-touches, sit-ups) can injure the back. Avoid twisting of the back by squarely facing the direction of movement. Move toward or away from your center of gravity. Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. Comfortable, low heeled shoes provide good foot support and reduce the risk of slipping, stumbling, or turning your ankle. 1. Incorrect: When sitting, keep knees slightly higher than the hips. 2. Incorrect: Flexion of the spine with the legs straight (toe-touches, sit-ups) can injure the back. 6. Incorrect: Holding an object close to your body when lifting puts less strain on your back.
The charge nurse is evaluating a new nurse, who is preparing to administer a bolus enteral feeding to a client. The client receiving a proton pump inhibitor. The new nurse checks the pH of aspirated gastric fluid to determine feeding tube placement. The pH reading is 6. Which actions taken by the new nurse requires intervention by the charge nurse? 1. Prepares to initiate feeding since pH is 6. 2. Tells the client that the feeding tube needs to be replaced. 3. Notify the primary healthcare provider of the finding. 4. Inspect the aspirated contents for color and consistency. 5. Pushes air into tube to check correct placement.
1, 2, 3, 5 Rationale 1., 2., 3., & 5. Correct: These actions are incorrect and requires intervention by the charge nurse. The normal stomach pH value is 1 to 4; however, when a client is receiving medications to decrease stomach acidity, the pH of the gastric aspirate may be as high as 6 and similar to the pH of respiratory secretions. Small intestines aspirates can also have a pH equal to or higher than 6. A pH of 6 does not confirm correct tube placement. It is not necessary to replace the feeding tube at this time. Look at the aspirated contents for color and consistency. There is nothing abnormal to indicate that the primary healthcare provider needs to be notified. Placing air into the tube will not tell you that tube is in correct place. This is not reliable for tube placement. 4. Incorrect: This is a correct action and does not require intervention by the charge nurse. The nurse should inspect the aspirated stomach contents for color and consistency to determine correct feeding tube placement. Gastric contents are cloudy, green, tan, or off-white, bloody or brown.
Which teaching points would the nurse include in a client's nutritional teaching plan to accomplish the goal of a gluten free diet? 1. Gluten is a protein found in barley. 2. Potatoes are a starchy food that can be eaten. 3. Milk is restricted on a gluten free diet. 4. Pure, non-contaminated oats are an acceptable grain food that the client can consume. 5. Eating food containing wheat may result in diarrhea. 6. Increase fiber in the diet.
1, 2, 4, 5 Rationale 1., 2., 4., & 5. Correct: A gluten-free diet is used in the treatment of celiac disease. Gluten is a protein found in barley, rye, and wheat. All products containing these grains are to be avoided. The main starchy foods that a person can eat are made with rice, corn, potatoes, quinoa, and Tapioca. In addition, pure oats that have not been cross-contaminated with wheat, barley and/or rye can be safely consumed by most individuals with celiac disease or other gluten sensitivity. Accidentally ingesting food with gluten may result in abdominal pain and diarrhea. Some people do not experience signs and symptoms, but this does not mean it is not damaging their small intestines. Even trace amounts of gluten may be damaging. 3. Incorrect: Fruits, vegetables, nuts, diary products and meats not prepared with gluten containing ingredients can be eaten. 6. Incorrect: A reduction in the fiber content of the diet is also frequently recommended.
The nurse is assessing a pregnant client who thinks she is in labor. Which statement by the client would alert the nurse that the client is likely experiencing true labor? 1. "The pain is in my back, and comes around to my abdomen." 2. "The contractions seem to increase when I begin walking around." 3. "The pain is in my lower abdomen and groin." 4. "My contractions are coming every 5 minutes." 5. "Changing my position does not help with the pain intensity."
1, 2, 4, 5 Rationale 1., 2., 4., & 5. Correct: All of these are signs of true labor. 3. Incorrect: The pain from true labor is in the back and comes around to the abdomen.
A client diagnosed with celiac disease has been prescribed a gluten-free diet. Which meal, if chosen by the client, would indicate to the nurse that the client understands this diet? 1. Grilled trout with mixed vegetables 2. Pan seared steak with brown rice 3. Vegetable omelet with biscuit and butter 4. Baked chicken with green salad 5. Broiled salmon with corn on the cob 6. Calf liver with mashed potatoes and gravy
1, 2, 4, 5 Rationale 1., 2., 4., & 5. Correct: Fresh meats, fish and poultry (not breaded, batter-coated or marinated), fruits and vegetables are allowed on a gluten-free diet. 3. Incorrect: Vegetables and eggs are good, but the biscuit will not be tolerated by the client. Biscuits are made with wheat. 6. Incorrect: Gravy is thickened with flour, which is not tolerated in a person with celiac disease.
Which assessment finding would the nurse expect in a client diagnosed with Paget's disease? 1. Hearing loss 2. Walking with a limp 3. Muscle weakness 4. A shuffled gait 5. Bow-legged 6. Numbness in lower extremities
1, 2, 5, 6 Rationale 1., 2., 5., & 6. Correct: Paget's disease is a chronic skeletal bone disorder in which there is excessive bone resorption followed by the marrow being replaced by fibrous connective tissue. The new bone is larger, disorganized, and weak. An overgrowth of bone in the skull can cause hearing loss or headaches. These clients have severe pain, may walk with a limp, and may become bow-legged. With the spine affected by Paget's disease the lower extremity may have tingling and numbness from spinal nerve root compression. 3. Incorrect: Muscle weakness is not a symptom. 4. Incorrect: This is a manifestation of Parkinson's disease which is related to brain and nerve signals. It is not related to Paget's disease.
What sign and symptom should the nurse expect to find during the physical assessment of a client who has a history of rheumatoid arthritis? 1. Nodules over bony prominences 2. Reports of bedtime stiffness lasting over 1 hour 3. Reports of weight loss 4. Cool, swollen joints 5. Joint deformity 6. Low grade fever
1, 3, 5, 6 Rationale 1., 3., 5., & 6. Correct: Firm bumps of tissue (nodules) over bony prominences, such as on elbows, are called rheumatoid nodules, and are a sign of rheumatoid arthritis. Over time, rheumatoid arthritis can cause joints to deform and shift out of place. Weight loss is a common symptom of rheumatoid arthritis. Inflammation is a normal part of the immune response. However, inflammation from RA is part of the problem. The same substances that cause inflammation of the joints can also cause a fever. RA also causes an increase in metabolic rate, which can also result in a fever. 2. Incorrect: Morning stiffness that can last for hours is a symptom of rheumatoid arthritis. 4. Incorrect: Affected joints will be tender, red, warm, and swollen.
A client with a radial fracture reports itching under the cast. What nursing action is appropriate? 1. Apply an ice pack for 10-15 minutes. 2. Slip a plastic spatula in the cast to rub itching area. 3. Sprinkle baby powder into the cast. 4. Elevate the cast on a pillow. 5. Use a blow dryer on cool setting.
1, 5 Rationale 1., & 5. Correct: These actions will change the sensation of itching. Applying something cool, such as a breeze from a cool blow-dryer, or an ice pack that will not get the cast wet help change the sensation for the client. 2. Incorrect: No objects should be placed under the cast as injury can occur. 3. Incorrect: Avoid applying lotions, oils, deodorant, or powder in or around the cast. The skin can become irritated. 4. Incorrect: Raising the cast on a pillow will help reduce swelling under the cast in the first 24 to 72 hours after a cast is applied, but it does not help with itching.
A client diagnosed with ulcerative colitis has a new prescription for a biologic agent. What is the priority education the nurse needs to make certain the client receives? 1. If you miss a dose, take it as soon as you remember. 2. Stay away from people who are sick. 3. Do not receive a live vaccine while using a biologic agent. 4. Common side effects include headache and cold symptoms.
2 Rationale 2. Correct: Biologics are immunomodulators which means that they alter the body's immune response. Since these agents can suppress the immune system, making the client more prone to infection. Biologics are used to treat many inflammatory conditions, such as ulcerative colitis, rheumatoid arthritis, and psoriatic arthritis. They can also be used in adults and children to treat Crohn's disease or juvenile idiopathic arthritis. 1. Incorrect: If the client misses a dose of the medicine, they should take it as soon as they remember, and then go back to your regular injection schedule. Do not use extra medicine to make up the missed dose. But this is not the priority at of the options available. 3. Incorrect: Although clients taking a biologic agent should not receive a "live" vaccine, this is not the priority. The vaccine may not work as well during this time, and may not fully protect the client from disease. Live vaccines include measles, mumps, rubella (MMR), polio, rotavirus, typhoid, yellow fever, varicella (chickenpox), or zoster (shingles). 4. Incorrect: Common side effects do include headache and cold symptoms. However, is this the priority for client education? No.
Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? You answered this question Correctly 1. Flat on the bed 2. Elevate foot of the bed 3. Position of comfort 4. Dependent position
2 Rationale 2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below the knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to prevent hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operatively is a normal occurrence, and elevating the foot of the bed along with the use of an ACE wrap will help prevent swelling.
A client, scheduled for a total hysterectomy for advanced cervical cancer, is crying and states, "I want to have more children! I do not know if I should have this procedure." Which response by the nurse is most appropriate? 1. "Cryotherapy may be a treatment option for you." 2. "Tell me more about your concerns." 3. "You might want to delay surgery until you are sure this is the option for you." 4. "Your health should be your priority right now. You need to have this surgery to live."
2 Rationale 2. Correct: This may be anticipatory grieving and being scared. Encourage the client to talk about her concerns and feelings. Let the client talk. She may need reassurance that she is making the right decision. 1. Incorrect: Cryotherapy is destruction of tissue by freezing with liquid nitrogen. Cryotherapy may be used with precursor lesions (mild to moderate dysplasia). It is not an appropriate treatment for advanced cervical cancer. 3. Incorrect: The cancer is already in an advanced stage. Will the waiting help her survive? 4. Incorrect: This is non-therapeutic communication and will make the client feel she must defend her feelings.
The charge nurse is evaluating the care a staff nurse is providing to a client who has just returned from open carpal tunnel release surgery. Which action by the staff nurse requires intervention by the charge nurse? 1. Monitors the dressing for tightness. 2. Places hand at the level of the heart. 3. Instructs nursing assistant to check vital signs hourly. 4. Performs neurovascular check to extremity. 5. Checks dressing for drainage.
2, 3 Rationale 2., & 3. Correct: The hand should be placed above the level of the heart to decrease edema. Vital signs are needed every 15 minutes for the first hour. 1. Incorrect: This is a correct measure. The client's dressing should be monitored for tightness. No need for the charge nurse to intervene. 4. Incorrect: We would worry about compartment syndrome with tightness and excess bleeding with drainage. Neurovascular checks are important with this client and should be done. No need for the charge nurse to intervene. 5. Incorrect: This is a correct measure. The client's dressing should be monitored for drainage. No need for the charge nurse to intervene.
Question: An 58-year-old client is experiencing ongoing fecal incontinence with 6-7 small, brown, liquid stools each day. The client eats a regular diet, does not receive any stool softeners or laxatives, and sits in the wheelchair for 1hour three times a day. What action should the nurse take? 1. Limit dietary fiber to 10 g daily. 2. Increase fluid intake to 2000 mL/day 3. Consider isometric abdominal and gluteal exercises. 4. Establish regular time for elimination. 5. Digitally eliminate the fecal impaction.
2, 3, 4, 5 Rationale 2., 3., 4., & 5. Correct: Sufficient fluid is needed to keep the fecal mass soft. But take note of some patients or older patients having cardiovascular limitations requiring less fluid intake. Movement promotes peristalsis. Abdominal exercises strengthen abdominal muscles that facilitate defecation. Most people defecate following the first daily meal or coffee, as a result of the gastrocolic reflex. Stool that remains in the rectum for long periods becomes dry and hard; debilitated patients, especially older patients, may not be able to pass these stools without manual assistance. 1 Incorrect: Assist patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetable, whole grains) per day. Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged.
Which interventions would the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophageal reflux disease (GERD)? 1. Provide small, low carbohydrate meals in the morning and evening. 2. Drinking decaffeinated tea is acceptable. 3. Administer esomeprazole as prescribed. 4. Encourage switching from smoking to chewing tobacco. 5. Sit upright for 3 hours after a meal. 6. Do not eat within 1hour of going to bed.
2, 3, 5 Rationale 2., 3., & 5. Correct: Gastroesophageal reflux disease is a disorder that results from stomach acid moving backward from the stomach into the esophagus. GERD usually happens because the lower esophageal sphincter (LES) — the muscular valve where the esophagus joins the stomach — opens at the wrong time or does not close properly. All of these actions are correct to help alleviate GERD. Caffeine increase acid secretion. Decaffeinated tea is allowed. Esomeprazole is a proton pump inhibitor that decreases the amount of acid produced in the stomach. It is best for the client to sit upright for 3 hours after a meal. 1. Incorrect: The client needs small, frequent meals throughout the day. And should eat a low fat diet. Fatty foods increase stomach acid. 4. Incorrect: Both smoking and chewing tobacco will increase acid secretion in the stomach. 6. Incorrect: Do not eat 2 to 3 hours before going to bed. Lying flat will delay emptying and increase reflux.
The nurse cares for a client after a gastroscopy examination. Which nursing interventions are appropriate post-procedure? 1. Administer small sip of water to assess gag reflex. 2. Monitor for throat pain. 3. Observe for hematemesis. 4. Evaluate bowel elimination frequency. 5. Monitor respiratory effort. 6. Assess oxygen saturation level.
2, 3, 5, 6 Rationale 2., 3., 5, & 6. Correct: A gastroscopy examination uses a flexible fiber-optic tube to visualize the esophagus and/or stomach. Accidental perforation of the esophagus may occur during endoscopy. If pain or bleeding occur following the procedure, notify the primary healthcare provider. The nurse should monitor for hematemesis, respirations, and oxygen saturation to ensure the scope did not damage any structures like the esophagus or lungs. 1. Incorrect: The throat is numbed before the procedure to inhibit the gag reflex and to allow the scope to pass freely. Therefore, it is important to maintain NPO status until the gag reflex returns. 3. Incorrect: Because the kidneys are not affected during this procedure, monitoring intake and output is not an important intervention. 4. Incorrect: Because the bowels are not affected during this procedure, this is not an important intervention.
What information should a nurse include when preparing discharge education for a client diagnosed with gastroesophageal reflux disease (GERD)? 1. Foods that may trigger an attack include apple juice, cream cheese, and oatmeal. 2. Lose weight slowly at a rate of 1 kilogram per week. 3. Only eat three small meals per day. 4. Avoid tight-fitting clothing. 5. Wait at least 1 hour after eating to lie down.
2, 4 Rationale 2., & 4. Correct: Excess pounds (kg) put pressure on the abdomen, pushing up the stomach and causing acid to back up into the esophagus. Work to slowly lose weight, no more than 1-2 pounds (0.5-1 kg) per week. Avoid tight-fitting clothing. Clothes that fit tightly around the waist put pressure on the abdomen and the lower esophageal sphincter. 1. Incorrect: These foods are safe for the client with GERD to eat. Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine. 3. Incorrect: Eat 6 small meals per day. Avoid eating 3 large meals. 5. Incorrect: Don't lie down immediately after a meal. Wait at least 3 hours after eating. Gastric acid is more likely to go up into the esophagus if the client lies down immediately.
Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client? 1. Onset of nausea and vomiting 2. Contraction every 3 minutes, lasting 20 seconds 3. Maternal blood pressure 140/90 4. Late decelerations in the fetal heart rate
4 Rationale 4. Correct: Late decelerations are a serious condition in which the heart rate of a fetus lowers below baseline usually after the peak of a contraction and signifies impaired placental exchange of blood flow and oxygen to the fetus. Late decelerations requires medical intervention on the part of a healthcare professional because the status of the infant is likely compromised. 1. Incorrect: Many laboring clients become nauseated and vomit during labor. Also, common side effects of oxytocin include nausea and vomiting. This would not require the discontinuation of oxytocin. 2. Incorrect: There is nothing wrong with these contractions. 3. Incorrect: Maternal hypotension requires discontinuation of oxytocin. This BP is not worrisome.
