A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?

Contractions are strong to palpation.

Cervix is dilating at 1 cm every 4 hr.

Consistent contractions last 80 seconds.

Contractions occur every 90 seconds.

Answer and Explanation

The Correct Answer is D

A. Strong contractions are expected with oxytocin augmentation and do not require a decrease in the infusion rate.
B. A cervical dilation rate of 1 cm every 4 hours is slow but does not indicate the need to decrease oxytocin.
C. Contractions lasting 80 seconds are prolonged but do not necessarily indicate hyperstimulation.
D. Contractions occurring every 90 seconds suggest uterine tachysystole, which can compromise fetal oxygenation and requires a decrease in the oxytocin infusion rate.

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Correct Answer is D

Explanation

A. Taking the client to the bathroom after administering a preoperative sedative increases the risk of falls.
B. Surgical site verification should be completed before administering the preoperative medication.
C. Teaching should be done before giving the medication, as the sedative may impair learning and recall.
D. Raising the side rails helps ensure client safety by preventing falls after the medication has been administered.

A. Explain to the client the consequences of refusal. B. Identify the reason for the client's refusal. C. Document the client's refusal in the medical record. D. Inform the provider of the client's refusal.

Correct Answer is B

Explanation

A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.

B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.

C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.

D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.

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A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?

Nursing Test Bank

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