a nurse is caring for a client who is in labor and is receiving oxytocin which of the following findings indicates that the nurse should increase the
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam

1. A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

Correct answer: B

Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.

2. A client is to receive thrombolytic therapy. Which of the following factors should be recognized as a contraindication to the therapy?

Correct answer: A

Rationale: Thrombolytic therapy involves the use of medications to dissolve blood clots. Hip arthroplasty (joint replacement surgery) performed recently is a contraindication to thrombolytic therapy due to the risk of bleeding. Elevated sedimentation rate, exercise-induced asthma, and elevated platelet count are not contraindications to thrombolytic therapy.

3. For abdominal inspection, in which of the following positions should a patient be placed?

Correct answer: C

Rationale: The supine position is ideal for abdominal inspection as it allows the healthcare provider to easily access and examine the abdomen. In the supine position, the patient lies flat on their back with arms at their sides, providing a clear view and access to the abdominal area for inspection.

4. When caring for a client who speaks a language different from their own, what action should the nurse take?

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

5. A client has diaper dermatitis. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Diaper dermatitis, also known as diaper rash, is a common condition in babies or clients who wear diapers. The primary intervention for diaper dermatitis is to apply a protective barrier cream, such as zinc oxide ointment, to the irritated area. This helps to protect the skin from irritants and promotes healing. Wiping stool from the skin using baby wipes may further irritate the skin, and talcum powder is no longer recommended due to potential respiratory risks when inhaled. Therefore, the correct action for the nurse in this scenario is to apply zinc oxide ointment to the irritated area.

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