A nurse is caring for a client who has a prescription for furosemide, which of the following laboratory tests should the nurse monitor?

Rationale:

A. Withhold the medication until the provider signs the prescription: Waiting for the provider's signature before administering a telephone order may delay critical care. Verbal or telephone orders can be acted upon immediately if clearly understood, documented, and later signed by the provider within the facility’s required timeframe.

B. Record the date and time of the telephone prescription: Accurate documentation includes noting the date and time the telephone order was received. This ensures clarity, legal compliance, and proper sequencing of medical events in the client's record.

C. Request that the provider confirm the read-back of the prescription: A read-back process reduces the risk of medication errors by confirming that the nurse correctly heard and understood the provider’s order. It is a Joint Commission-recommended safety practice.

D. Ask the provider to spell out the name of the medication: Asking the provider to spell out high-risk or sound-alike medications helps avoid transcription errors. This step is especially important when communication clarity is compromised over the phone.

E. Instruct another nurse to record the prescription in the medical record: The nurse receiving the order is responsible for documenting it. Delegating this task to another nurse increases the chance of miscommunication and errors, and violates proper protocol.

Rationale:

A. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy uterus located above the umbilicus suggests uterine atony, which indicates that the oxytocin may not have been effective. This finding is not expected 30 minutes after administering oxytocin.

B. Client report of burning with urination: Burning during urination is unrelated to oxytocin administration and may point toward a urinary tract infection. It does not reflect the expected physiological response to uterine stimulation for controlling postpartum hemorrhage.

C. Saturation of perineal pad in 15 min: Continued excessive bleeding despite oxytocin administration indicates treatment failure and requires immediate intervention. Oxytocin should reduce uterine bleeding; thus, ongoing hemorrhage is not an expected finding.

D. Client report of uterine cramping: Uterine cramping is an expected response to oxytocin, which works by stimulating uterine smooth muscle contractions. These cramps help compress blood vessels at the placental site, reducing postpartum bleeding and promoting involution.