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A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations
- B. Moderate variability of the FHR
- C. Cessation of uterine dilation
- D. Prolonged active phase of labor
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, which can worsen with oxytocin administration due to increased uterine contractions. This can lead to fetal distress and hypoxia. Late decelerations are a sign to stop or decrease the oxytocin infusion and notify the provider. Moderate variability of the FHR (B) is a reassuring sign of fetal well-being. Cessation of uterine dilation (C) may indicate a stalled labor but is not a contraindication for initiating oxytocin. Prolonged active phase of labor (D) may warrant oxytocin augmentation but is not a contraindication.
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A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on skeletal muscle and cardiac function. It is essential to have calcium gluconate readily available in case of magnesium toxicity.
Incorrect Choices:
A: Restricting hourly fluid intake is not necessary for a client with preeclampsia receiving magnesium sulfate IV.
C: Assessing deep tendon reflexes every 6 hours is not the most critical action to take to prevent or manage magnesium toxicity.
D: Monitoring intake and output every 4 hours is important for overall client assessment but is not directly related to managing magnesium toxicity in this scenario.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Place the client in a supine position for 30 min following the first dose of anesthetic solution.
- B. Administer 1000 mL of dextrose 5% in water prior to the first dose of anesthetic solution
- C. Monitor the client’s blood pressure every 5 min following the first dose of anesthetic solution.
- D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. This is crucial because epidural anesthesia can cause hypotension, a common side effect. Monitoring the client's blood pressure closely allows for early detection of hypotension and prompt intervention to prevent potential complications like fetal distress. Placing the client in a supine position for 30 min (A) is incorrect as it can lead to hypotension; administering dextrose solution (B) is not necessary for epidural anesthesia; ensuring NPO status (D) is important for other procedures but not specifically for epidural anesthesia.
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps prevent aortocaval compression, a potential cause of hypotension after epidural anesthesia. When the client is lying on their back, the weight of the uterus can compress the vena cava, reducing venous return and cardiac output, leading to hypotension. Turning the client to a side-lying position relieves this compression, improving blood flow and helping to stabilize blood pressure.
Summary:
B: Applying oxygen may be beneficial in some cases, but it does not directly address the underlying cause of hypotension in this scenario.
C: Massaging the fundus is not indicated for hypotension following epidural anesthesia.
D: Assisting the client to empty their bladder may be important for overall comfort and prevention of complications, but it does not address the hypotension directly.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to monitor fetal heart rate and movement patterns. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, providing valuable information about the fetal well-being. Maintaining the client NPO (Option A) is not necessary for a nonstress test. Placing the client in a supine position (Option B) can decrease blood flow to the fetus. Instructing the client to massage the abdomen (Option C) may lead to inaccurate test results.
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). During pregnancy, elevated blood glucose levels can indicate gestational diabetes, which can pose risks to both the mother and the fetus. A fasting blood glucose level of 180 mg/dL is significantly above the normal range of 74 to 106 mg/dL and warrants immediate attention from the healthcare provider to initiate appropriate management and monitoring.
Choice A (Hematocrit 37%): Falls within the normal range for a pregnant woman and does not raise immediate concerns.
Choice B (Creatinine 0.9 mg/dL): Within the normal range and not typically a cause for concern at this level.
Choice C (WBC count 11,000/mm3): Slightly elevated but can be a normal physiological response to pregnancy due to increased blood volume and does not necessarily indicate a problem.
In summary, the other choices do not indicate an urgent issue requiring immediate provider notification