A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.

Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

She was assisted to the bathroom where she voided 150 mL of clear yellow urine.

Lochia rubra is moderate with small clots, no foul odor noted.

The fundus is firm at the umbilicus.

The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.

There is no pain, redness, or swelling in the calves.

A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.

The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

Answer and Explanation

The Correct Answer is ["-"]

Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.

Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

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Correct Answer is ["0.72"]

Explanation

Step 1 is to calculate the total amount of oxytocin in the IV bag. This is done by multiplying the total volume of the bag by the concentration of oxytocin. In this case, the bag contains 5 units of oxytocin in 500 mL, so the concentration is 5 units ÷ 500 mL = 0.01 units/mL.

Step 2 is to convert the prescribed dose from milliunits/min to units/hour. There are 1000 milliunits in a unit and 60 minutes in an hour, so 12 milliunits/min = 12 ÷ 1000 units/min = 0.012 units/min. Then, 0.012 units/min × 60 min/hour = 0.72 units/hour.

Step 3 is to calculate the infusion rate in mL/hour. This is done by dividing the prescribed dose in units/hour by the concentration of oxytocin in units/mL. So, 0.72 units/hour ÷ 0.01 units/mL = 72 mL/hour. Therefore, the nurse should set the infusion pump to 72 mL/hour.

A. Praise the client for her actions and offer to discuss ways to decrease consumption even more. B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit. C. Notify child protective services of the client’s illicit drug use and probable child endangerment. D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Correct Answer is A

Explanation

The correct answer is A. Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Why? During pregnancy, any amount of alcohol poses a risk to the developing fetus, but abruptly shaming or forcing action may not be effective. The best approach is motivational interviewing, which involves acknowledging the client's reduction while encouraging further progress. A supportive conversation can help guide the client toward complete cessation of alcohol use.

Here’s why the other options are incorrect:

B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit – While alcohol cessation is the goal, forcing the client without a supportive approach can lead to resistance. Routine blood alcohol testing is not standard unless substance dependence is suspected.
C. Notify child protective services of the client’s illicit drug use and probable child endangerment – Alcohol is not classified as an illicit drug, and reporting at this stage would be premature unless clear evidence of abuse or harm to the fetus exists.
D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy – Disulfiram (Antabuse) is not recommended in pregnancy, as it may cause adverse effects. Instead, behavioral counseling and support groups are preferred interventions.

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Naxlex Comprehensive Predictor Exams

A patient in active labor is prescribed oxytocin 12 milliunits/min intravenously (IV). The IV bag contains 5 units of oxytocin in 500 mL of lactated Ringer’s solution. How many mL/hour should the nurse set the infusion pump to? (Enter numerical value only) .

Correct Answer is ["0.72"]

Explanation

A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

Correct Answer is A

Explanation

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