Author Question: The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client ... (Read 64 times)

danielfitts88 · **on:** Jul 22, 2018

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and in-tensity.

The priority nursing intervention in caring for the client is to: 1. Provide pain relief measures.
2. Promote ambulation every 30 minutes.
3. Prepare the client for an amniotomy.
4. Monitor the oxytocin (Pitocin) infusion closely.

Question 2

The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea.

The nurse interprets that these symptoms are because of stimulation of which cranial nerve (CN)? 1. Vagus (CN X)
2. Hypoglossal (CN XII)
3. Spinal accessory (CN XI)
4. Glossopharyngeal (CN IX)

lin77x · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1

Rationale: Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

Answer to Question 2

1

Rationale: The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also responsible for the decrease in heart rate because approximately 75 of all parasympathetic stimulation is carried by the vagus nerve. CN IX is responsible for taste in the posterior two thirds of the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck and shoulder movement. CN XII is responsible for tongue movement.