🔷 Uterine contractions lasting 90 seconds indicate uterine tachysystole/hyperstimulation, which is an adverse effect of oxytocin infusion.

🔷 Oxytocin stimulates uterine smooth muscle, and excessive stimulation can reduce uteroplacental blood flow.

🔷 Prolonged contractions can decrease fetal oxygenation because the uterus does not relax long enough between contractions.

🔷 The nurse should recognize this finding as unsafe and prepare to stop or reduce the oxytocin infusion according to facility protocol.

🔷 The client should also be repositioned, IV fluids increased as prescribed, and the fetal heart rate monitored closely for signs of distress.

Moderate variability of the FHR

🔷 Moderate variability is a reassuring fetal heart rate finding.

🔷 It usually indicates adequate fetal oxygenation and an intact fetal nervous system.

Uterine contractions every 2 min

🔷 Contractions every 2 min can be acceptable during labor if they are not too long or too strong.

🔷 The concerning finding is a contraction lasting 90 seconds, because prolonged contraction time can impair fetal oxygenation.

FHR 150/min

🔷 A fetal heart rate of 150/min is within the normal baseline range of 110 to 160/min.

🔷 This finding does not indicate an adverse effect of oxytocin.

🟢 Enoxaparin 30 mg subcut every 12 hr is the safest documentation because it uses the correct dose, route, and frequency.

🟢 The abbreviation mg correctly represents milligrams, which matches the prescribed dose.

🟢 The route is written as subcut, which is safer than using error-prone abbreviations such as SQ or SC.

🟢 The frequency every 12 hr is clear and avoids unsafe shorthand.

🟢 Accurate transcription is essential because enoxaparin is an anticoagulant, and documentation errors can increase the risk of bleeding or underdosing.

Enoxaparin 30 mg SQ q AM and q HS

🟢 SQ and q are unsafe abbreviations and should be avoided in medication documentation.

🟢 “q AM and q HS” does not accurately match the prescription of every 12 hr.

Enoxaparin 30 mcg SC q12 hour

🟢 mcg is incorrect because the prescription is for 30 mg, not micrograms.

🟢 SC and q12 are also unsafe abbreviations, making this transcription unsafe.

Condition: Pulmonary edema

🔵 Pulmonary edema is most likely because the client has heart failure history, severe sudden dyspnea, crackles, jugular vein distension, pitting edema, tachycardia, and hypoxemia.

🔵 These findings indicate fluid overload backing up into the lungs, which interferes with oxygen exchange.

🔵 The oxygen saturation of 87% despite 10 L via nonrebreather shows severe respiratory compromise.

🔵 The ABG shows respiratory acidosis with low pH, high PaCO₂, and low PaO₂, meaning the client is not ventilating or oxygenating effectively.

🔵 Cool clammy extremities, restlessness, and lethargy suggest poor perfusion and worsening oxygen deprivation.

Actions

Administer sublingual nitroglycerin

🔵 Sublingual nitroglycerin helps reduce preload by causing venous dilation.

🔵 Lowering preload decreases the amount of blood returning to the heart, reducing pulmonary congestion.

🔵 This helps relieve chest tightness, dyspnea, and fluid pressure in the lungs.

🔵 Nitroglycerin is commonly used in acute pulmonary edema when blood pressure is adequate, and this client’s blood pressure is 156/88 mm Hg.

🔵 The nurse should monitor blood pressure closely because nitroglycerin can cause hypotension.

Administer an IV diuretic

🔵 An IV diuretic, such as furosemide, is a priority medication for pulmonary edema related to heart failure.

🔵 It removes excess fluid through the kidneys and decreases intravascular volume.

🔵 Reducing fluid volume helps decrease pulmonary congestion and improves oxygenation.

🔵 IV administration is preferred in an emergency because it works faster than oral therapy.

🔵 The nurse should monitor urine output, blood pressure, electrolytes, and respiratory status after administration.

Parameters

Frothy, pink-tinted sputum

🔵 Frothy, pink-tinted sputum is a classic sign of worsening pulmonary edema.

🔵 It occurs when fluid and small amounts of blood leak into the alveoli.

🔵 Monitoring sputum helps determine whether pulmonary fluid accumulation is improving or worsening.

🔵 A decrease in frothy sputum suggests better alveolar gas exchange and reduced congestion.

🔵 Increasing frothy sputum requires urgent reassessment and rapid provider notification.

Urinary output

🔵 Urinary output is important because the client is expected to receive an IV diuretic.

🔵 Adequate urine output shows that the kidneys are responding and excess fluid is being removed.

🔵 Monitoring output helps evaluate whether treatment is reducing fluid overload.

🔵 Low urine output may indicate poor renal perfusion, worsening heart failure, or ineffective diuresis.

🔵 The nurse should also assess daily weight and lung sounds to evaluate fluid status.

Place the client in lateral position

🟣 Place the client in a lateral position because the fetal tracing shows minimal variability with recurring late decelerations, which indicates uteroplacental insufficiency.

🟣 Late decelerations occur when the fetus is not receiving enough oxygen during contractions.

🟣 Repositioning the client to the side improves maternal venous return, increases uterine blood flow, and helps improve fetal oxygenation.

🟣 This is especially important after epidural placement because the client’s blood pressure dropped from 149/87 to 119/75, which can reduce placental perfusion.

🟣 Lateral positioning is a priority intrauterine resuscitation intervention for a nonreassuring fetal heart rate pattern.

Apply oxygen via face mask at 10 L/min

🟣 Apply oxygen via face mask at 10 L/min to increase maternal oxygen delivery and support fetal oxygenation during late decelerations.

🟣 Recurring late decelerations with minimal variability suggest the fetus may be experiencing hypoxia.

🟣 Oxygen by face mask provides a higher oxygen concentration than room air and is used during intrauterine resuscitation.

🟣 This action is appropriate while the nurse continues fetal monitoring and prepares to notify the provider.

🟣 Oxygen therapy helps improve oxygen transfer across the placenta until the fetal heart rate pattern stabilizes.

🔷 “The client was administered 4 units of regular insulin” is correct because it is objective, factual, clear, and medication-specific.

🔷 Proper documentation should include what was given, the dose, and the medication name without judgmental wording.

🔷 This entry avoids blaming, vague descriptions, or incident-report language in the client’s medical record.

🔷 The medical record is a legal document, so entries must be accurate, concise, timely, and based on observed facts.

🔷 Clear medication documentation supports continuity of care and reduces the risk of duplicate dosing or medication errors.

“The client is uncooperative and refused to take their morning medication.”

🔷 The word uncooperative is judgmental and should not be used in objective nursing documentation.

🔷 A better entry would describe the client’s exact behavior or quote the client’s refusal.

“A 2 centimeter by 2 centimeter amount of purulent drainage was noted during a dressing change.”

🔷 This documentation is unclear because drainage should be described by amount, color, odor, and consistency, not as “2 cm by 2 cm amount.”

🔷 The measurement may describe the wound or drainage area, but it does not accurately quantify the drainage.

“A medication error was made on a previous shift. The client’s vital signs are stable.”

🔷 Medication errors should be reported through the facility’s incident reporting system, not documented as blame in the client’s chart.

🔷 The medical record should include the client’s assessment findings and interventions without referencing an incident report or assigning fault.

🟢 Urine specific gravity 1.001 indicates very dilute urine, which can occur with hypervolemia because excess fluid lowers urine concentration.

🟢 Specific gravity measures the concentration of particles in urine, and a low value suggests increased fluid volume or reduced concentrating ability.

🟢 In fluid volume excess, the kidneys may excrete more water, producing urine with a low specific gravity.

🟢 The normal range is approximately 1.005 to 1.030, so 1.001 is below the expected range.

🟢 This finding supports fluid overload more than the other listed laboratory values.

Serum calcium 10 mg/dL

🟢 A serum calcium of 10 mg/dL is within the expected range of 9 to 10.5 mg/dL.

🟢 This value does not indicate hypervolemia.

Serum sodium 138 mEq/L

🟢 A serum sodium of 138 mEq/L is within the expected range of 136 to 145 mEq/L.

🟢 Although dilutional hyponatremia can occur with fluid overload, this sodium level is normal.

Urine pH 6

🟢 A urine pH of 6 is within the normal range of 4.6 to 8.

🟢 Urine pH reflects urine acidity or alkalinity, not fluid volume status.

⚖️ Battery occurs when the nurse performs intentional physical contact without the client’s consent.

⚖️ The client clearly refused the injection by stating, “I don’t want that injection.”

⚖️ Giving the injection anyway violates the client’s right to autonomy and bodily control.

⚖️ In nursing, even a prescribed treatment can become battery if it is performed after a competent client refuses it.

⚖️ The nurse should have stopped, assessed the client’s concern, provided teaching, and notified the provider if needed.

Assault

⚖️ Assault is a threat or attempt to touch a client without consent.

⚖️ In this case, the injection was actually given, so the act became battery.

Coercion

⚖️ Coercion involves forcing or pressuring a client to make a decision through threats, intimidation, or manipulation.

⚖️ The issue here is not persuasion; it is actual unwanted physical contact.

A breach of duty

⚖️ A breach of duty occurs when a nurse fails to meet the expected standard of care.

⚖️ Although the nurse acted improperly, the specific legal tort committed by giving an unwanted injection is battery.

🔷 A client who is 2 days postoperative following a colon resection is the most appropriate assignment for a float nurse from the postpartum unit.

🔷 This client is likely stable enough for routine postoperative nursing care such as vital signs, pain control, incision assessment, mobility support, intake and output, and bowel function monitoring.

🔷 A postpartum nurse has general nursing skills that can transfer well to caring for a stable postoperative client.

🔷 Float nurses should be assigned clients with stable conditions and predictable outcomes.

🔷 The nurse manager should avoid assigning the float nurse clients who require specialized precautions, complex neurologic assessment, or high-risk urologic postoperative monitoring.

A client who has tuberculosis and is on airborne precautions

🔷 A client with tuberculosis requires strict airborne precautions, including appropriate room placement and fit-tested N95 respirator use.

🔷 This assignment is less appropriate for a postpartum float nurse because it requires infection-control practices that may be less familiar in that specialty area.

A client who has a head injury and requires neurological checks every 4hr

🔷 A client with a head injury requires accurate and ongoing neurological assessment.

🔷 This is not the best assignment for a float nurse because subtle neurological changes can indicate serious deterioration.

A client who is 1 day postoperative following a transurethral resection of the prostate

🔷 A client who is 1 day postoperative following TURP requires close monitoring for bleeding, urinary obstruction, bladder spasms, and complications related to continuous bladder irrigation.

🔷 This care is more specialized and less predictable than routine postoperative colon resection care.