The nurse is caring for a patient whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of:
1. uterine contractions occurring every 8 to 10 minutes.
2. an FHR of 180 with absence of variability.
3. when the patient needs to void.
4. when the patient's amniotic membranes rupture.
2
1. Incorrect. The oxytocin should be discontinued if uterine hyperstimulation occurs. Ute-rine contractions that are occurring every 8 to 10 minutes do not qualify as hyperstimulation.
2. Correct. This FHR is nonreassuring. The oxytocin should be immediately discontinued and the physician should be notified.
3. Incorrect. This is not an indication to immediately discontinue the oxytocin induction or to call the physician.
4. Incorrect. Unless there is a change in the FHR pattern that is nonreassuring or the patient experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the patient's membranes have ruptured.
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a. anxiety c. delirium b. dyspnea d. pain
The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by 3-pound weight loss and (2) risk for impaired skin integrity related to inadequate nutrition
The major difference between the two diagnoses is that the second diagnosis: a. needs no defined nursing interventions. b. needs medical intervention. c. will not need to be evaluated. d. reflects a problem that does not yet exist.
A patient is hospitalized with new onset of manic behavior. It would be important for the nurse to inspect and report results of which laboratory tests? Select all that apply
a. Calcium b. Creatinine c. Potassium d. Drug screens e. Thyroid function