A 1,000 ml bag of Lactated Ringer's solution containing 10 units of Pitocin (oxytocin) is infusing via an 18 g peripheral IV in the left forearm at 125 ml per hour, with 300 ml remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag's infusion is complete.
1. Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain?
[pic]A) Vital signs.
[pic]B) Vaginal discharge.
[pic]C) Uterine firmness.
[pic]D) Oral intake.
2. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia?
[pic]A) Risk for injury.
[pic]B) Impaired physical …show more content…
[pic]D) Wait until Mr. Wilson arrives at the hospital with the children, and talk to him before he goes in to see his wife.
The healthcare provider prescribes two units of packed red blood cells (PRBCs) to be transfused as soon as possible. Marie signs the consent form, and a blood sample for the type and crossmatch is obtained.
14. What is the correct way for Marie's nurse to prepare for the blood transfusion?
[pic]A) Reduce complications of rapid transfusion by using a blood warmer.
[pic]B) Start an additional IV using a 16 or 18 gauge angiocath.
[pic]C) Prime the Y-set blood tubing using the normal saline that is already infusing.
[pic]D) Monitor for fluid overload by assessing lab results, urine output, and respiratory status.
Marie's nurse is getting ready to administer the first unit of blood when the nursery nurse brings in Marie's infant son and states that Marie needs to feed him because it has been four hours since the infant last nursed. The infant is sleeping soundly in the crib.
15. What is the best thing for Marie's nurse to do?
[pic]A) Encourage Marie to nurse the infant while proceeding with the blood administration.
[pic]B) Delay hanging the blood for 15 to 20 minutes until Marie finishes nursing the infant.
[pic]C) Request that the infant be brought back in an hour to give the blood time to take effect.