A nurse is caring for a client on the medical surgical unit

Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider?

Rationale for correct choices

• oxytocin: The client is term, contracting regularly, and already 3 cm dilated, indicating early active labor progression. Oxytocin may be anticipated to augment labor when contractions are present but not yet efficient. The presence of infection risk (fever, malodorous discharge) also increases the need to progress labor toward delivery.

• nalbuphine: The client reports pain that increases to 8 during contractions, indicating a need for pharmacologic analgesia. Nalbuphine is an opioid analgesic used in labor for moderate to severe pain and is appropriate for intrapartum pain management. It can be anticipated when the client requests stronger pain relief before progression to active labor.

Rationale for incorrect choices

• magnesium sulphate: This medication is used for seizure prophylaxis in preeclampsia or for neuroprotection in preterm labor. The client’s blood pressure is within normal range, and gestation is 38 weeks, so there is no indication for magnesium sulfate.

• misoprostol: Cervical ripening is not required because the cervix is already 3 cm dilated with active contractions. Misoprostol would not be indicated when labor is already progressing, especially in the presence of suspected infection, where accelerating delivery is preferred.

• hydralazine: Hydralazine is an antihypertensive used for severe hypertension in pregnancy. The client’s blood pressure is 128/82 mm Hg, which does not indicate hypertensive management.

A. Changing a dressing for a client who has a stage 3 pressure injury: Dressing changes for complex wounds require assessment of the wound, evaluation for signs of infection, and clinical judgment to select appropriate interventions. These responsibilities fall within the nurse’s scope of practice and should not be delegated to assistive personnel.

B. Obtaining a signed consent from a client for a screening colonoscopy: Obtaining informed consent involves explaining the procedure, risks, benefits, and answering client questions, which requires nursing knowledge and legal responsibility. This task cannot be delegated to assistive personnel.

C. Measuring I&O for a client who is receiving parenteral nutrition: Monitoring and documenting intake and output for a client receiving parenteral nutrition involves critical interpretation of fluid balance, which may affect electrolyte management and therapy adjustments. This task requires nursing judgment and is not appropriate for delegation.

D. Providing postmortem care for a client who experienced cardiac arrest: Postmortem care is a routine, noninvasive task that does not require nursing judgment. Assistive personnel can perform this task, including cleaning and positioning the body and preparing the client for the family, making it appropriate for delegation.

E. Transferring a client from a bed to a chair with a mechanical lift: Assisting with safe client mobility using a mechanical lift is within the scope of an assistive personnel’s role. This task does not require clinical decision-making but ensures safety and proper technique, making it suitable for delegation.