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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Brainstorming sessions are designed to generate new ideas and solutions by encouraging free thinking and creativity among participants. This approach can be effective in generating
innovative strategies to address public health concerns.
B. While a community-wide program may be part of addressing the issue, it does not inherently involve generating new ideas but rather implementing existing strategies on a larger scale.
C. Role-playing with nurses may be a training method to improve communication or intervention skills, but it is not specifically aimed at generating new ideas to address public health concerns.
D. Personal discussions with clients are important for providing individualized care and support but may not directly contribute to generating new ideas to address community-wide public health concerns.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
A. It would not be appropriate to place the client on restraints as this would increase agitation and he is not violent.
B. The client may have a urinary tract infection (UTI) that is causing fever, hypotension, and confusion. Monitoring elimination can help assess the severity of the infection and the need for antibiotics.
C. Dimming the lights can help reduce sensory overload and agitation in the client.
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