A nurse is caring for a client in the labor and delivery unit.

Select the 4 findings that indicate a complication of labor.

A. "Instill prescribed drops whenever your eyes feel irritated.": Eye drops for glaucoma are prescribed on a strict schedule to maintain consistent intraocular pressure reduction. Administering them only when irritation occurs can lead to ineffective treatment and progression of optic nerve damage.

B. "Apply gentle pressure to the outer corner of your eye following eye drop administration.": The correct technique is to apply gentle pressure to the inner corner (punctal area) of the eye to prevent systemic absorption of the medication. Pressure at the outer corner does not prevent systemic effects and is not recommended.

C. "Place the tip of the container in the lower conjunctival sac to administer.": Eye drops should be placed in the lower conjunctival sac, but the instruction is incomplete without guidance on avoiding contact with the eye surface to prevent contamination. Proper placement technique includes holding the dropper above the sac without touching the eye.

D. "Wait 5 minutes before administering different eye drop medications": Waiting 5 minutes between different eye drops allows adequate absorption and prevents one medication from washing out the other. This practice optimizes therapeutic effects and minimizes interactions between multiple ocular medications.

A.A gastric residual volume (GRV) of 250 mL is a finding that requires monitoring but typically does not require "immediate" intervention or the cessation of feeding. Current evidence-based guidelines often suggest that feedings should not be held unless the GRV exceeds 500 mL in a single measurement or if the client shows signs of intolerance (e.g., abdominal distension, nausea). While 250 mL indicates a slight delay in gastric emptying, it is not an acute emergency compared to the risk of aspiration from supine positioning.

B.The client is lying in a supine position: The client lying in a supine position requires immediate intervention. Clients receiving enteral feedings must have the head of the bed elevated to at least 30° to 45° at all times to prevent gastric reflux and aspiration. In a post-laryngectomy client, the risk is even higher because the anatomical changes to the upper airway make it easier for regurgitated feeding to enter the trachea. The nurse must immediately raise the head of the bed to ensure the client's safety.

C. The infusion pump for administering continuous feeding is turned off: The pump being turned off interrupts nutrition delivery, which is undesirable, but it does not pose an immediate risk to the client’s safety. Correcting the pump can be done after addressing more urgent issues.

D. The enteral feeding bag and tubing are not dated: Lack of dating increases the risk of infection due to prolonged use, but this is a routine safety concern and does not require immediate intervention compared with high gastric residual volumes that pose aspiration risk.