A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

Rationale:

A. Maintain bed elevation at 20°: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30°–45° during and after enteral feedings. A 20° elevation is insufficient to prevent gastric reflux and aspiration.

B. Check for gastric residual every 12 hr: Gastric residuals should generally be checked every 4–6 hours for clients receiving continuous enteral feedings. Waiting 12 hours increases the risk of feeding intolerance or aspiration from undetected residual accumulation.

C. Flush the tubing with 30 mL of water every 4 hr: Routine flushing helps prevent tube occlusion and maintains patency. It also ensures that the client receives adequate hydration, especially with continuous feeding systems.

D. Place enough formula in the container to last 18 hr: Formula in an open system should not hang longer than 4 hours due to the risk of bacterial contamination. Adding 18 hours’ worth increases the chance of microbial growth and infection.

Rationale:

A. "I will obtain the client's weight every other day.": Clients receiving TPN require daily weight monitoring to evaluate fluid balance and nutritional effectiveness. Monitoring every other day may delay detection of complications such as fluid overload or inadequate nutrition.

B. "I will monitor the client's blood glucose level every 8 hours.": Blood glucose levels should typically be monitored every 4 to 6 hours, especially during initiation or rate adjustments of TPN. Longer intervals may miss signs of hyperglycemia, a common complication of TPN.

C. "I will hang a new bag of TPN and IV tubing every 24 hours.": Changing the TPN solution and tubing every 24 hours is standard protocol to prevent catheter-related bloodstream infections. TPN solutions are high in glucose, which can promote microbial growth if not properly managed.

D. "I will increase the rate of the TPN infusion to ensure the correct amount is given.”: The TPN infusion rate must never be adjusted without a provider’s order. Altering the rate can lead to serious complications such as hyperglycemia, electrolyte imbalance, or fluid overload.