A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Answer and Explanation

The Correct Answer is ["732"]

To calculate the total intake, we need to convert all measurements to the same unit, in this case, milliliters (mL).

1 ounce (oz) is approximately equal to 29.5735 mL.

Also, it’s important to note that when ice chips melt, they become about half their volume in water. So, 100 mL of ice chips would become about 50 mL of wate

Let’s calculate:

Juice: 4 oz * 29.5735 = 118.294 mL

Tea: 6 oz * 29.5735 = 177.441 mL

Ice chips: 100 mL * 0.5 = 50 mL

IV bolus: 150 mL

Broth: 8 oz * 29.5735 = 236.588 mL

Adding all these together:

118.294 mL (juice) + 177.441 mL (tea) + 50 mL (ice chips) + 150 mL (IV bolus) + 236.588 mL (broth) = 732.323 mL

So, the nurse should record 732 mL of intake on the client’s record (rounded to the nearest whole number).

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Correct Answer is D

Explanation

A) Contractions are strong in intensity: Strong contractions are expected during the active phase of the first stage of labor. While the nurse should monitor the strength of contractions, strong intensity alone is not typically a cause for concern during this phase.

B) Client reports feeling contractions in the lower back: Back pain during contractions is common, especially during the active phase of labor. It is often associated with the pressure of the baby's head on the sacral nerves. Although it can be uncomfortable, it is not typically a significant concern unless it is accompanied by other symptoms.

C) Contractions occurring every 3 to 5 minutes: This is a normal finding during the active phase of the first stage of labor. Contractions becoming more regular and frequent are expected as labor progresses.

D) Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can be detrimental to both the mother and the fetus. Uterine hyperstimulation can reduce placental perfusion, leading to fetal distress and maternal complications such as uterine rupture. Therefore, the nurse should report contractions lasting longer than 90 seconds to the provider for further evaluation and management.

A. Insert an indwelling urinary catheter. B. Administer oxygen by nonrebreather mask at 5 L/min. C. Methylergonovine 0.2 mg IM now. D. Obtain laboratory study of prothrombin and partial thromboplastin time.

Correct Answer is C

Explanation

Answer: C. Methylergonovine 0.2 mg IM now.

A. Insert an indwelling urinary catheter.
Inserting an indwelling urinary catheter can be appropriate in a postpartum client, especially if there are concerns about bladder distension, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage. This action does not require clarification.

B. Administer oxygen by nonrebreather mask at 5 L/min.
Although oxygen is commonly delivered at higher rates (10-15 L/min) via a nonrebreather mask, the administration of oxygen at 5 L/min is not harmful. This may be based on the client’s current oxygen needs, but the flow rate might warrant a review.

C. Methylergonovine 0.2 mg IM now.
Methylergonovine is used to control postpartum hemorrhage, but it is contraindicated in clients with hypertension. This client has elevated blood pressure (146/94 mm Hg), and administering methylergonovine could further increase the risk of hypertensive complications. Therefore, this prescription requires clarification due to the risk of hypertensive crisis.

D. Obtain laboratory study of prothrombin and partial thromboplastin time.
Ordering coagulation studies such as prothrombin time (PT) and partial thromboplastin time (PTT) is appropriate, especially in a postpartum client with heavy bleeding, to assess clotting status and rule out any coagulation disorders. This prescription does not require clarification.

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A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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