A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery.
Which action is most important for the nurse to implement?
Discuss the character of labor from endogenous vs. exogenous oxytocin.
Ask the healthcare provider to discuss the issue with the client.
Discuss alternative ways to support the client's birth plan.
Explain the indications for induction related to post-term pregnancy.
The Correct Answer is C
Choice A rationale:
Discuss the character of labor from endogenous vs. exogenous oxytocin. While it is important to educate the client about the difference between endogenous (naturally occurring) and exogenous (administered) oxytocin, this information may not address the client's primary concern. The client is refusing the prescribed oxytocin infusion and wants a "natural" delivery. Therefore, discussing alternative ways to support her birth plan is more pertinent.
Choice B rationale:
Ask the healthcare provider to discuss the issue with the client. Involving the healthcare provider in the discussion is a reasonable step, but it should not be the first action taken. The nurse can initiate a conversation with the client to explore her concerns and preferences before escalating the issue to the healthcare provider.
Choice C rationale:
Discuss alternative ways to support the client's birth plan. This is the correct choice because it directly addresses the client's refusal of the oxytocin infusion and desire for a "natural" delivery. Exploring alternative methods for inducing or facilitating labor in a way that aligns with the client's birth plan is essential.
Choice D rationale:
Explain the indications for induction related to post-term pregnancy. Explaining the indications for induction is important for educating the client about the medical reasons behind the prescribed treatment. However, this information may not immediately address the client's refusal of the oxytocin infusion. The nurse should first explore the client's concerns and preferences regarding her birth plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.
Choice B rationale:
Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.
Choice C rationale:
Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.
Choice D rationale:
Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.
Correct Answer is ["21"]
Explanation
Let’s calculate the infusion rate step by step:
- Convert 1 liter to mL: 1 liter = 1000 mL.
- Calculate total infusion time in minutes: 12 hours = 12 × 60 = 720 minutes.
- Calculate the rate in mL/min: Rate = Total Volume ÷ Total Time = 1000 mL ÷ 720 min = 1.39 mL/min.
- Calculate the drip rate in gtt/min: Drip Rate = Rate (mL/min) × Drip Factor (gtt/mL) = 1.39 mL/min × 15 gtt/mL = 20.85 gtt/min.
If rounding is required, we round to the nearest whole number. So, the nurse should regulate the infusion to 21 gtt/min.
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