The nurse conducting an eye examination notes that the client ...

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The nurse conducting an eye examination notes that the client exhibits rapid, involuntary, oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as:
 
  1. Nystagmus
  2. Photophobia
  3. Unequal pupils
  4. Impaired consensual response

Question 2

A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which of the following findings indicates that the rate of the infusion needs to be decreased?
 
  1. Increased urinary output
  2. A fetal heart rate of 180 beats/min
  3. Three contractions occurring in a 10-minute period
  4. Adequate resting tone of the uterus palpated between contractions

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Answer to Question 1

1

Rationale: Nystagmus is characterized by the presence of involuntary, rapid eye movements and is an abnormal finding caused by disease or as a side effect of some medications. Unequal pupils are noted by direct examination of pupil size and reaction to light and are abnormal in most cases. Consensual response is a normal finding that is noted when one pupil contracts, even though the other pupil has a light shone into it. Photophobia is an abnormal sensation and is seen as a sensitivity of the client to light.

Answer to Question 2

2

Rationale: A normal fetal heart rate is 120 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachy-cardia, which can occur from excessive uterine activity. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute peri-od. The uterus should return to resting tone between contractions, and there should be no evi-dence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

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