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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Insisting the client use direct eye contact may be intimidating or uncomfortable for the client, especially in a mental health setting where individuals may have varying levels of comfort with eye contact.
B. Seating the client at such a distance may create a physical barrier and hinder effective communication between the nurse and the client.
C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially during a sensitive interview.
D. Leaning in slightly when speaking to the client demonstrates attentiveness and facilitates a sense of closeness and engagement in the conversation, which can help build rapport and trust.
Correct Answer is C
Explanation
A. Limit each of the client's visitors to 1 hr per day. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and
the client's condition, not solely on the presence of a radiation implant.
B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.
C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.
D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate
protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.
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