A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?

Increase the rate of the oxytocin infusion.

Administer dinoprostone transvaginally

Place the client in a lateral position.

Assist the client to empty their bladder.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Increase the rate of the oxytocin infusion: Increasing oxytocin would intensify uterine contractions, which can worsen uteroplacental insufficiency and exacerbate late decelerations. This action is unsafe and contraindicated when late decelerations are present.

B. Administer dinoprostone transvaginally: Dinoprostone is used to ripen the cervix or induce labor, not to correct fetal distress caused by uteroplacental insufficiency. Administering it in this scenario would not address the underlying problem and could increase fetal risk.

C. Place the client in a lateral position: Lateral positioning improves uteroplacental blood flow and oxygen delivery to the fetus, which can reduce late decelerations. It is an immediate, safe, and effective nursing intervention to relieve fetal stress caused by decreased placental perfusion.

D. Assist the client to empty their bladder: While bladder distention can affect uterine contractions and comfort, it does not directly address late decelerations. Emptying the bladder may be beneficial for other reasons, but repositioning the client takes priority in improving fetal oxygenation.

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Correct Answer is C

Explanation

Rationale:

A. Serum calcium level: Cushing’s disease does not typically cause elevated calcium levels. Calcium levels are usually normal unless there is an underlying bone disorder or concurrent condition affecting calcium metabolism.

B. Lymphocyte count: Cortisol excess in Cushing’s disease suppresses the immune system, leading to lymphopenia rather than an increased lymphocyte count. A decreased lymphocyte count is more consistent with the disease process.

C. Serum glucose level: Elevated cortisol levels increase gluconeogenesis and decrease glucose uptake by cells, resulting in hyperglycemia. Clients with Cushing’s disease often exhibit elevated blood glucose as a direct effect of excess cortisol.

D. Serum potassium level: Cortisol has mineralocorticoid activity, promoting potassium excretion by the kidneys. As a result, clients with Cushing’s disease commonly have hypokalemia rather than increased serum potassium levels.

A. Report the pump has a frayed cord and proceed with the infusion. B. Check the expiration date on the safety inspection sticker of the pump C. Obtain a surge protector that can accommodate the pump and several other appliances. D. Verify that the extension cord for the pump is ungrounded

Correct Answer is B

Explanation

Rationale:

A. Report the pump has a frayed cord and proceed with the infusion: Using a pump with a frayed cord is unsafe and poses a risk of electrical shock or malfunction. The pump should not be used until it is repaired or replaced, so proceeding with the infusion is inappropriate.

B. Check the expiration date on the safety inspection sticker of the pump: Verifying that the infusion pump has a current safety inspection ensures that the device has been tested and is functioning properly. This action is essential to prevent mechanical failure and maintain patient safety during IV therapy.

C. Obtain a surge protector that can accommodate the pump and several other appliances: Infusion pumps should be plugged directly into a properly grounded outlet to ensure consistent power and prevent electrical hazards. Connecting multiple devices through a surge protector can overload the circuit and compromise pump function.

D. Verify that the extension cord for the pump is ungrounded: Using an ungrounded extension cord increases the risk of electrical shock and device malfunction. Only properly grounded outlets and cords should be used with infusion pumps to maintain safety.

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A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?

Nursing Test Bank

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