Nokea
A client has received a special formulation of oxytocin for intranasal use. The nurse understands that the rationale for using this formulation of the drug involves which effect?
- A. Antistimulating properties on the uterus
- B. Diuretic effect
- C. Stimulation of the milk ejection reflex
- D. Control of antepartum bleeding
Correct Answer: C
Rationale: Oxytocin, when administered intranasally, stimulates the milk ejection (milk letdown) reflex. Oxytocin has uterine-stimulating properties, not antistimulating properties, on the uterus. Tocolytics have an antistimulating effect on the uterus. Oxytocin has an antidiuretic effect, which might lead to a danger of excessive fluid volume (water intoxication), and not a diuretic effect. Oxytocin is given IM during the third stage of labor to produce uterine contractions and control postpartum, and not antepartum, bleeding and hemorrhage.
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Immediately before starting an IV infusion of oxytocin (Pitocin), the nurse assesses which of the following?
- A. Client's blood pressure
- B. Fetal heart rate
- C. Client's blood glucose
- D. Client's temperature
- E. Client's respiratory rate
Correct Answer: A,B,E
Rationale: Immediately before starting an IV infusion of oxytocin (Pitocin), the nurse assesses the fetal heart rate and the client's blood pressure, pulse, and respiratory rate.
A nurse is caring for a pregnant client receiving oxytocin. The client is in the third stage of labor. The nurse would expect to administer oxytocin by which route?
- A. Intravenous
- B. Intramuscular
- C. Subcutaneous
- D. Intranasal
Correct Answer: B
Rationale: Oxytocin is given intramuscularly (IM) during the third stage of labor. It is the time period from when the neonate is expelled until the placenta is expelled. Oxytocin is given intramuscularly to produce uterine contractions and control postpartum bleeding and hemorrhage. Oxytocin is not given intravenously, subcutaneously, or intranasally during the third stage of labor.
After teaching a group of students about uterine drugs, the instructor determines that the teaching was successful when the students identify which of the following as oxytocic drugs?
- A. Oxytocin (Pitocin)
- B. Methylergonovine (Methergine)
- C. Estradiol (Estrace)
- D. Indomethacin (Indocin)
- E. Misoprostol (Cytotec)
Correct Answer: A,B,E
Rationale: Oxytocin (Pitocin), methylergonovine (Methergine), and misoprostol (Cytotec) are classified as oxytocic drugs. Indomethacin is a tocolytic. Estradiol is an estrogen.
A nurse is preparing to administer oxytocin (Pitocin) intravenously to a client based on the understanding that this drug is used for which of the following reasons?
- A. Gestational diabetes and a large fetus
- B. Rh problems
- C. Premature rupture of membranes
- D. Uterine inertia
- E. Pregnancy-induced hypertension
Correct Answer: A,B,C,D,E
Rationale: A nurse may be asked to administer oxytocin (Pitocin) intravenously to a client with the following: gestational diabetes and a large fetus, Rh problems, premature rupture of membranes, uterine inertia, or pregnancy-induced hypertension.
A client is admitted for tocolytic therapy for preterm labor. The client states, 'I'm so afraid that I'm so early. Is my baby okay? What if the drug doesn't help?' Based on the client's statement, the nurse would identify which nursing diagnosis as the priority?
- A. Anxiety
- B. Risk for Injury
- C. Impaired Gas Exchange
- D. Excess Fluid Volume
Correct Answer: A
Rationale: Based on the client's statements, the nurse would identify Anxiety as the priority nursing diagnosis because of the client's stated concern for her fetus and cessation of labor. Risk for Injury and Excess Fluid Volume would be more appropriate for a client receiving oxytocin. Impaired Gas Exchange would be appropriate if the client was experiencing adverse reactions related to the tocolytic.