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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.

B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.

C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.

D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.

A. A client who has heart failure and reports shortness of breath while ambulating B. A client who has abdominal pain and is vomiting coffee-ground emesis C. A client who has benign prostatic hyperplasia and is unable to urinate D. A client who had an open cholecystectomy and has green drainage from the T-tube

Correct Answer is B

Explanation

A. This client's symptom of shortness of breath while ambulating indicates possible worsening heart failure, which requires prompt assessment but is not immediately life-threatening.

B. Vomiting coffee-ground emesis suggests upper gastrointestinal bleeding, which could be

indicative of a serious condition such as a gastrointestinal ulcer or tear and requires immediate assessment to determine the cause and initiate appropriate treatment.

C. While urinary retention in a client with benign prostatic hyperplasia requires attention, it is not as urgent as upper gastrointestinal bleeding.

D. Green drainage from the T-tube in a client who had an open cholecystectomy may indicate bile leakage, which requires assessment and intervention, but upper gastrointestinal bleeding takes precedence due to its potential for rapid deterioration.

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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?

Nursing Test Bank

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Correct Answer is D

Explanation

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