Question

A provider orders Butorphanol tartrate 0.02 mg/kg IV every 3-4 hours as needed for labor pain for a client who weighs 80 kg. The medication is supplied as 2 mg/mL. How many milliliters (mL) should the nurse administer per dose? (Round to the nearest tenth if applicable. Numeric answer only.)

Answer 1

Correct Answers:

0.8

Rationale :

Calculation

Step 1:

Calculate the ordered dose

0.02 mg/kg×80 kg=1.6 mg

Step 2:

Calculate volume to administer

Available:

2 mg=1 mL

Formula:

2 mg1.6 mg×1 mL =0.8 mL

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Answer 2

Correct Answers:

Discontinue the oxytocin infusion

Rationale :

⚠️ The priority action is to discontinue the oxytocin infusion because the client is experiencing uterine tachysystole (contractions lasting 120 seconds) with recurrent late fetal heart rate decelerations.

⚠️ Oxytocin stimulates uterine contractions, and excessive stimulation can decrease uteroplacental perfusion, reducing oxygen delivery to the fetus.

⚠️ Late decelerations indicate possible uteroplacental insufficiency and fetal compromise, requiring immediate correction of the cause.

⚠️ Stopping oxytocin reduces uterine activity and allows time for uterine relaxation and improved blood flow to the placenta.

⚠️ After discontinuing oxytocin, the nurse should continue intrauterine resuscitation measures such as repositioning the client, increasing IV fluids as indicated, and applying oxygen if prescribed or needed according to facility protocol.

⚠️ The nurse should then reassess the fetal heart rate pattern and notify the provider if abnormalities persist.

⚠️ Therefore, stopping the oxytocin infusion is the priority intervention because it addresses the cause of fetal distress.

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Answer 3

Correct Answers:

Notify provider and prepare for potential neonatal resuscitation

Rationale :

🟢 Green-colored amniotic fluid indicates the presence of meconium, which suggests that the fetus may have experienced stress and passed stool before birth.

🟢 Meconium-stained fluid increases the risk of meconium aspiration syndrome (MAS), where the newborn inhales meconium into the lungs, causing respiratory complications.

🟢 The nurse should notify the provider so the healthcare team can prepare for possible neonatal interventions after delivery.

🟢 The neonatal resuscitation team may need to be available because the newborn could require assessment and respiratory support after birth.

🟢 The nurse should continue close fetal heart rate monitoring because meconium may be associated with fetal compromise.

🟢 Prompt recognition and preparation improve newborn outcomes and allow immediate response if respiratory distress occurs.

🟢 Therefore, notifying the provider and preparing for possible neonatal resuscitation is the priority action.

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Answer 4

Correct Answers:

Stop infusion and administer calcium gluconate

Rationale :

⚠️ The priority action is to stop the magnesium sulfate infusion and administer calcium gluconate because the client is showing signs of magnesium toxicity.

⚠️ Magnesium sulfate toxicity can cause respiratory depression, decreased deep tendon reflexes, and decreased urine output.

⚠️ A respiratory rate of 10 breaths/min, 1+ reflexes, and urine output of 20 mL/hr indicate excessive magnesium accumulation and impaired elimination.

⚠️ Magnesium is excreted through the kidneys, so decreased urine output increases the risk of toxic magnesium levels.

⚠️ Calcium gluconate is the antidote for magnesium toxicity because it reverses the effects of excessive magnesium on the neuromuscular and respiratory systems.

⚠️ The nurse should act immediately because worsening toxicity can lead to respiratory arrest and cardiac complications.

⚠️ Therefore, stopping the infusion and preparing/administering calcium gluconate is the priority intervention.

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Answer 5

Correct Answers:

Respect client's wishes and offer alternative comfort measures

Rationale :

🌎 The nurse should respect the client’s cultural beliefs and personal preferences regarding pain management during labor while providing supportive care.

🌎 Clients have the right to make informed decisions about their care, including the decision to decline pain medication after receiving appropriate education.

🌎 A culturally competent nurse recognizes that beliefs about pain, childbirth, and medication use vary among individuals and cultures.

🌎 Offering alternative comfort measures such as breathing techniques, relaxation methods, positioning, massage, and emotional support respects the client’s choice while promoting comfort.

🌎 The nurse should assess the client’s understanding of available options and ensure the decision is informed rather than based on misunderstanding.

🌎 Respecting autonomy and cultural preferences helps build trust and improves the nurse-client relationship.

🌎 Therefore, respecting the client’s wishes and offering alternative comfort measures is the most appropriate nursing action.

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Answer 6

Correct Answers:

Administer a tocolytic medication (e.g., terbutaline)
Reduce or stop oxytocin infusion if infusing
Increase IV fluids to promote hydration

Rationale :

Administer a tocolytic medication (e.g., terbutaline)

⚠️ Tocolytic medications are used to relax uterine smooth muscle and decrease excessive uterine contractions.

⚠️ During uterine tachysystole, frequent contractions can reduce the amount of time between contractions for the placenta to receive adequate blood flow.

⚠️ This can decrease uteroplacental perfusion and may result in fetal oxygen compromise.

⚠️ Medications such as terbutaline may be prescribed to slow uterine activity and improve fetal oxygenation.

⚠️ The goal of a tocolytic is not to stop normal labor completely but to reduce excessive uterine stimulation.

⚠️ The nurse should continue monitoring the fetal heart rate after administration to evaluate improvement.

⚠️ Therefore, administering a tocolytic is an appropriate intervention for uterine tachysystole.

Reduce or stop oxytocin infusion if infusing

⚠️ Oxytocin increases uterine contractions, and excessive dosing can cause uterine tachysystole.

⚠️ If the client develops more than 5 contractions in 10 minutes, the nurse should anticipate reducing or discontinuing oxytocin to decrease uterine stimulation.

⚠️ Stopping oxytocin allows the uterus to relax and improves blood flow to the placenta.

⚠️ Excessive contractions may lead to late fetal heart rate decelerations due to decreased oxygen exchange.

⚠️ The nurse should assess the fetal heart tracing after stopping the infusion.

⚠️ Oxytocin can usually be restarted at a lower rate once the contraction pattern normalizes and the fetus is tolerating labor.

⚠️ Therefore, reducing or stopping oxytocin is a priority intervention when it contributes to tachysystole.

Increase IV fluids to promote hydration

⚠️ Increasing IV fluids can improve maternal circulating volume and support uteroplacental blood flow.

⚠️ Maternal dehydration can contribute to uterine irritability and may worsen contraction patterns.

⚠️ Improving hydration can help optimize conditions for fetal oxygen delivery.

⚠️ IV fluid administration is commonly included in intrauterine resuscitation measures when fetal intolerance occurs.

⚠️ This intervention supports the mother while other measures are used to decrease excessive contractions.

⚠️ The nurse should monitor maternal vital signs and fetal response after increasing fluids.

⚠️ Therefore, increasing IV fluids is an appropriate supportive intervention for tachysystole.

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Answer 7

Correct Answers:

Uterine hyperstimulation and fetal distress

Rationale :

⚠️ The findings indicate uterine hyperstimulation (tachysystole) caused by oxytocin and possible fetal distress due to decreased oxygenation.

⚠️ Uterine contractions lasting 120 seconds and occurring every 1½ minutes indicate excessively frequent and prolonged contractions, which reduce the time for uterine relaxation.

⚠️ During relaxation periods, blood flow through the placenta increases; therefore, excessive contractions can decrease uteroplacental perfusion and reduce fetal oxygen supply.

⚠️ A fetal heart rate of 100 bpm is bradycardia because the normal baseline fetal heart rate is approximately 110–160 bpm.

⚠️ Recurrent late decelerations indicate uteroplacental insufficiency, meaning the fetus is not tolerating the labor process well.

⚠️ The nurse should anticipate interventions such as stopping the oxytocin infusion, repositioning the client, increasing IV fluids as indicated, and notifying the provider if the pattern persists.

⚠️ Therefore, these findings represent oxytocin-induced uterine hyperstimulation with fetal compromise, not normal labor progression.

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Answer 8

Correct Answers:

"It stimulates uterine contractions and helps ripen the cervix."

Rationale :

🌸 Misoprostol is a prostaglandin medication used during labor induction to promote cervical ripening and help prepare the cervix for delivery.

🌸 It works by softening, thinning, and dilating the cervix while also stimulating uterine contractions to help initiate labor.

🌸 Cervical ripening is important because an unfavorable cervix may make labor induction less successful.

🌸 The medication is commonly administered before oxytocin to improve the likelihood of effective labor progression.

🌸 The nurse should monitor for excessive uterine activity because misoprostol can cause uterine tachysystole, which may affect fetal oxygenation.

🌸 Fetal heart rate and contraction patterns should be assessed regularly after administration.

🌸 Therefore, the correct explanation is that misoprostol ripens the cervix and stimulates uterine contractions to induce labor.

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Answer 9

Correct Answers:

Two arteries and one vein

Rationale :

👶 A normal umbilical cord contains three blood vessels: two umbilical arteries and one umbilical vein.

👶 The umbilical vein carries oxygenated, nutrient-rich blood from the placenta to the fetus.

👶 The two umbilical arteries carry deoxygenated blood and waste products from the fetus back to the placenta for removal.

👶 After delivery of the placenta, the nurse should examine the umbilical cord to confirm the presence of these three vessels.

👶 A cord containing only one artery and one vein is known as a single umbilical artery (two-vessel cord) and may be associated with fetal abnormalities.

👶 Assessing the umbilical cord vessels is part of the newborn assessment immediately after birth.

👶 Therefore, the expected finding is two arteries and one vein.

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Answer 10

Correct Answers:

Reposition the client

Rationale :

🔄 Variable decelerations are caused by umbilical cord compression, which temporarily decreases blood flow and oxygen delivery to the fetus.

🔄 The priority nursing action is to reposition the client because changing maternal position can relieve pressure on the umbilical cord and improve fetal oxygenation.

🔄 Common repositioning measures include placing the client in a side-lying position to improve uteroplacental blood flow.

🔄 The nurse should assess the fetal heart rate response after repositioning to determine whether the decelerations improve.

🔄 If variable decelerations persist, additional interventions may include stopping oxytocin if infusing, administering IV fluids, or preparing for further provider interventions.

🔄 Repositioning is a rapid, independent nursing action that directly addresses the likely cause of variable decelerations.

🔄 Therefore, repositioning the client is the priority intervention for variable fetal heart rate decelerations.

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QLexNursing

1 :
A provider orders Butorphanol tartrate 0.02 mg/kg IV every 3-4 hours as needed for labor pain for a client who weighs 80 kg. The medication is supplied as 2 mg/mL. How many milliliters (mL) should the nurse administer per dose? (Round to the nearest tenth if applicable. Numeric answer only.)

2 :
A nurse is caring for a laboring client receiving an oxytocin infusion. The nurse is reviewing the fetal monitoring strip and notes the client is having contractions lasting 120 seconds with the fetal heart rate tracing showing recurrent late decelerations. What is the priority nursing action?

3 :
A nurse is caring for a laboring client. The client's membranes have just ruptured, and the nurse notes green-colored amniotic fluid. Which nursing action is the most appropriate?

4 :
A nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. The client's assessment reveals a respiratory rate of 10 breaths/min, deep tendon reflexes of 1+, and urine output of 20 mL/hr. What is the priority nursing action?

5 :
A nurse is providing teaching to a client from a different cultural background who declines pain medication during labor. Which action should the nurse take?

6 :
A client in active labor is experiencing uterine tachysystole, defined as more than 5 contractions in 10 minutes over a 30-minute window. Which of the following interventions would the nurse anticipate the provider to order to correct this abnormal uterine activity? (Select All That Apply.)

8 :
A nurse is caring for a client who is being induced for labor. The provider prescribes misoprostol. Which of the following statements by the nurse best explains the purpose of this medication?

9 :
A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

10 :
A nurse is caring for a laboring client. The fetal heart rate monitor reveals variable decelerations. What is the priority nursing action?

QLexNursing

1 : A provider orders Butorphanol tartrate 0.02 mg/kg IV every 3-4 hours as needed for labor pain for a client who weighs 80 kg. The medication is supplied as 2 mg/mL. How many milliliters (mL) should the nurse administer per dose? (Round to the nearest tenth if applicable. Numeric answer only.)

2 : A nurse is caring for a laboring client receiving an oxytocin infusion. The nurse is reviewing the fetal monitoring strip and notes the client is having contractions lasting 120 seconds with the fetal heart rate tracing showing recurrent late decelerations. What is the priority nursing action?

3 : A nurse is caring for a laboring client. The client's membranes have just ruptured, and the nurse notes green-colored amniotic fluid. Which nursing action is the most appropriate?

4 : A nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. The client's assessment reveals a respiratory rate of 10 breaths/min, deep tendon reflexes of 1+, and urine output of 20 mL/hr. What is the priority nursing action?

5 : A nurse is providing teaching to a client from a different cultural background who declines pain medication during labor. Which action should the nurse take?

6 : A client in active labor is experiencing uterine tachysystole, defined as more than 5 contractions in 10 minutes over a 30-minute window. Which of the following interventions would the nurse anticipate the provider to order to correct this abnormal uterine activity? (Select All That Apply.)

8 : A nurse is caring for a client who is being induced for labor. The provider prescribes misoprostol. Which of the following statements by the nurse best explains the purpose of this medication?

9 : A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

10 : A nurse is caring for a laboring client. The fetal heart rate monitor reveals variable decelerations. What is the priority nursing action?

1 :
A provider orders Butorphanol tartrate 0.02 mg/kg IV every 3-4 hours as needed for labor pain for a client who weighs 80 kg. The medication is supplied as 2 mg/mL. How many milliliters (mL) should the nurse administer per dose? (Round to the nearest tenth if applicable. Numeric answer only.)

2 :
A nurse is caring for a laboring client receiving an oxytocin infusion. The nurse is reviewing the fetal monitoring strip and notes the client is having contractions lasting 120 seconds with the fetal heart rate tracing showing recurrent late decelerations. What is the priority nursing action?

3 :
A nurse is caring for a laboring client. The client's membranes have just ruptured, and the nurse notes green-colored amniotic fluid. Which nursing action is the most appropriate?

4 :
A nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. The client's assessment reveals a respiratory rate of 10 breaths/min, deep tendon reflexes of 1+, and urine output of 20 mL/hr. What is the priority nursing action?

5 :
A nurse is providing teaching to a client from a different cultural background who declines pain medication during labor. Which action should the nurse take?

6 :
A client in active labor is experiencing uterine tachysystole, defined as more than 5 contractions in 10 minutes over a 30-minute window. Which of the following interventions would the nurse anticipate the provider to order to correct this abnormal uterine activity? (Select All That Apply.)

8 :
A nurse is caring for a client who is being induced for labor. The provider prescribes misoprostol. Which of the following statements by the nurse best explains the purpose of this medication?

9 :
A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

10 :
A nurse is caring for a laboring client. The fetal heart rate monitor reveals variable decelerations. What is the priority nursing action?