The nurse is planning care for a client who just received 25 mcg of misoprostol (Cytotec) vaginally to ripen the cervix. Which interventions should the nurse plan to implement? (Select all that apply.)
a. Assist the client to the bathroom.
b. Position the client in a high Fowler position.
c. Assess the uterus for excessive contractions.
d. Monitor the fetal heart rate for at least 30 minutes.
ANS: C, D
The FHR should be monitored for at least 30 minutes for changes and the uterus should be assessed for excessive contractions. To reduce leakage, the woman should lie flat for 15 to 20 minutes after the gel form of prostaglandin is inserted. The client should not be assisted to the bathroom immediately or placed in a high Fowler position (head of bed up 90 degrees).
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