During the oliguric phase of acute renal failure, which of the following occurs?

Choice A rationale:

Urine output (UO) does not completely stop during the oliguric phase of acute renal failure. While it is significantly reduced, some urine production still occurs. Complete cessation of urine output is known as anuria, which is a more severe condition and a medical emergency.

Anuria may occur in the most severe cases of acute renal failure, but it is not the defining characteristic of the oliguric phase.

It's crucial to distinguish between oliguria and anuria, as their management approaches differ significantly.

Choice B rationale:

During the oliguric phase of acute renal failure, urine output (UO) is less than 400 mL/24 hours. This is the defining characteristic of this phase.

The decrease in urine output is due to damage to the kidneys' filtering units, known as nephrons. As a result, the kidneys are unable to filter waste products and excess fluids effectively from the blood, leading to their accumulation in the body.

This reduced urine output can lead to various complications, including fluid overload, electrolyte imbalances, and a buildup of waste products in the blood (uremia).

Choice C rationale:

Urine output (UO) is always measured during the oliguric phase of acute renal failure. It is a vital clinical indicator to monitor the severity of kidney dysfunction and guide treatment decisions.

Accurate measurement of urine output is essential for assessing fluid balance, kidney function, and the effectiveness of treatment interventions.

Choice D rationale:

Urine output (UO) is not greater than 500 mL/24 hours during the oliguric phase of acute renal failure. A urine output greater than 500 mL/24 hours would indicate a non-oliguric phase of acute renal failure or a potential recovery phase.

Choice A rationale:

Fetal heart rate of 90 beats per minute is a sign of fetal bradycardia, which is a serious and potentially life-threatening condition. It indicates that the fetus is not getting enough oxygen, and it can lead to fetal distress, brain damage, or even death.

Oxytocin can cause uterine hyperstimulation, which can reduce blood flow to the placenta and cause fetal bradycardia. Therefore, if the nurse observes a fetal heart rate of 90 beats per minute, it is essential to discontinue the oxytocin infusion immediately and notify the healthcare provider.

Choice B rationale:

Increased urinary output is not a direct contraindication to oxytocin administration. In fact, oxytocin can sometimes cause a decrease in urinary output due to its antidiuretic effects.

While a significant increase in urinary output could be a sign of fluid overload, it would not necessarily indicate that the oxytocin infusion needs to be discontinued. The nurse would need to assess the patient's overall fluid status and other clinical indicators to make this determination.

Choice C rationale:

Three contractions occurring within a 10-minute period is considered a normal contraction pattern during labor. It is not a sign of uterine hyperstimulation or fetal distress.

In fact, the goal of oxytocin administration is to achieve regular contractions that are occurring every 2-3 minutes and lasting 40-60 seconds. Therefore, this finding would not indicate that the oxytocin infusion needs to be discontinued.

Choice D rationale:

Adequate resting tone of the uterus palpated between contractions is a normal finding during labor. It indicates that the uterus is contracting effectively and is not at risk for uterine atony (lack of muscle tone).

This finding would not be a reason to discontinue the oxytocin infusion.