Nokea
A 32-year-old pregnant woman has been prescribed an IV infusion of oxytocin to induce labor. Which of the following interventions would be most appropriate for the nurse to implement before starting the IV infusion of oxytocin for the client?
- A. Ask the client to drink plenty of water
- B. Obtain an obstetric and general health history
- C. Examine for signs of water intoxication
- D. Place the client in an upright position
Correct Answer: B
Rationale: Before starting an IV infusion of oxytocin to induce labor, the nurse should obtain a complete obstetric history (e.g., parity, gravidity, previous obstetric problems, type of labor, stillbirths, abortions, live-birth infant abnormalities) and a general health history. Clients should not have water before labor, as the oxytocin may lead to water intoxication. The nurse should examine for any signs of water intoxication or fluid overload as a sign of an adverse reaction to the drug and need not assess this before administration of the medication. Placing the client in an upright position is advised when oxytocin is administered intranasally to facilitate the letdown of milk for breastfeeding.
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When explaining the action of oxytocin to a client, the nurse integrates knowledge of which of the following about the drug?
- A. Secretion by the anterior pituitary gland
- B. Uterine-stimulating properties
- C. Diuretic effects
- D. Vasopressor effects
- E. Stimulation of milk ejection
Correct Answer: B,D,E
Rationale: Oxytocin is a hormone secreted by the posterior pituitary gland that has uterine-stimulating properties, exerts antichuretic and vasopressor effects, and stimulates milk ejection.
A client receiving prescribed magnesium sulfate shows signs of dyspnea, tachycardia, and increased respiratory rate and rales. The nurse notices frothy sputum. Which of the following conditions should the nurse suspect?
- A. Pulmonary edema
- B. Water intoxication
- C. Renal failure
- D. Cardiac arrest
Correct Answer: A
Rationale: The client is most likely experiencing pulmonary edema. If there is an increase in respiratory rate of more than 20 respirations/min with the administration of magnesium sulfate, the nurse should assess the respiratory status for symptoms of pulmonary edema such as dyspnea, tachycardia, rales, and frothy sputum. In such cases, the primary health care provider is notified immediately because use of the drug may be discontinued or the dosage may be decreased. The danger of water intoxication is associated with oxytocin as it has an antidiuretic effect, and not with magnesium sulfate. Renal failure and cardiac arrest are not associated with magnesium sulfate.
A nurse should monitor a client for which of the following adverse reactions during the administration of tocolytic therapy to prevent uterine contractions?
- A. Fatigue
- B. Diaphoresis
- C. Diplopia
- D. Hypertension
- E. Prolonged vaginal bleeding
Correct Answer: A,B,C
Rationale: A nurse should monitor a client for the following adverse reactions during tocolytic therapy to prevent uterine contractions: fatigue, flushing, headache, diplopia, diaphoresis, hypotension, depressed reflexes, and flaccid paralysis.
A 30-year-old pregnant woman has been prescribed oxytocin. When assessing the client's drug regimen, the nurse understands that the client is taking vasopressors. Which of the following risks is the client most susceptible to if oxytocin is administered along with vasopressors?
- A. Anaphylactic shock
- B. Hypertension
- C. Respiratory failure
- D. Heart attack
Correct Answer: B
Rationale: Combining oxytocin with vasopressor drugs increases the risk of severe hypertension. Combining oxytocin and vasopressors does not increase the risk of heart attack or respiratory failure. Anaphylactic shock is associated with a hypersensitivity reaction and does not occur with the interaction of vasopressors and oxytocin.
A client is receiving terbutaline for preterm labor. After administering the drug, the nurse would be alert for which of the following as an adverse reaction?
- A. Diplopia
- B. Nervousness
- C. Tremor
- D. Palpitations
- E. Heartburn
Correct Answer: B,C,D
Rationale: Adverse reactions associated with terbutaline include nervousness, restlessness, tremor, headache, anxiety, hypertension, palpitations, arrhythmias, hypokalemia, and pulmonary edema. Diplopia and heartburn are associated with indomethacin.