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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Speaking directly into one of the client's ears may be ineffective if the client has bilateral hearing impairment or if the hearing impairment is not related to the ear anatomy.
B. Rephrasing sentences the client does not understand can help clarify communication and ensure the client receives necessary information.
C. Dropping voice volume at the end of sentences can make it difficult for the client to hear the entire message, especially if the client relies on lip-reading or amplification devices.
D. Exaggerating lip movements may not be helpful for all clients with hearing impairment and may not accurately convey the intended message. Instead, clear and natural lip movements should be used along with other communication strategies such as rephrasing sentences and facing the client directly.
Correct Answer is A
Explanation
A.
A. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.
B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.
C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.
D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.
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