The nurse is monitoring a woman who is receiving an oxytocin infusion to stimulate contractions. An assessment reveals contractions of 100 seconds with 50-second intervals between them. The first nursing action should be to:
a. Slow down the oxytocin infusion rate.
b. Discontinue the oxytocin infusion.
c. Increase the oxytocin infusion rate.
d. Notify the primary health care provider.
ANS: B
This assessment provides evidence of uterine hyperstimulation. Because hyperstimulation can lead to uteroplacental insufficiency, fetal compromise, uterine rupture, or a very rapid labor, the oxytocin should be stopped when contractions exceed 90 seconds in duration or there are less than 60 seconds between contractions. After the oxytocin is stopped, the physician must be notified.
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A) Used to prevent the bedclothes from touching all or part of the client's body B) Used to prevent clients from falling out of bed C) Used to help the client to change position while in bed D) Prevent abnormal plantar flexion or deformity
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a. "You will need to cut the hair shorter if infestation and nits are severe." b. "You can distinguish viable from nonviable nits, and remove all viable ones." c. "You can wash all nits out of hair with a regular shampoo." d. "You will need to remove nits with an extra-fine tooth comb or tweezers."
You are supervising a nursing student who is giving the patient instructions about how to use the pancreatic enzymes at home. The student tells the patient to mix the enzyme in a soft food like low-fat cottage cheese. What should you do first?
A. Allow the student to finish the patient teaching and then give the student positive feedback. B. Stop the student and give the patient the correct information. C. Encourage the student to report to the instructor and review medication instructions. D. Let the student finish and then take the student aside and review the information.