Nokea
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.
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When monitoring uterine contractions of a client receiving an oxytocin infusion, the nurse should notify the primary health care provider immediately if which of the following occur?
- A. No palpable relaxation of the uterus
- B. Significant change in client's blood pressure
- C. Significant change in fetal heart rhythm
- D. Significant change in rhythm of uterine contractions
- E. Significant change in frequency of uterine contractions
Correct Answer: A,B,C,D,E
Rationale: When monitoring uterine contractions, the nurse should notify the physician immediately if any of the following occur: a significant change in fetal heart rate or rhythm; a marked change in the frequency, rate, or rhythm of uterine contractions; uterine contractions lasting longer than 60 seconds; contractions occurring more frequently than every 2 or 3 minutes; no palpable relaxation of the uterus; a marked increase or decrease in the client's blood pressure or pulse; or any significant change in the client's general condition.
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.
A nurse suspects that a client receiving an oxytocic drug is developing water intoxication based on assessment of which of the following?
- A. Tachypnea
- B. Wheezing
- C. Confusion
- D. Hypoglycemia
- E. Hypotension
Correct Answer: A,B,C
Rationale: The nurse immediately reports any signs of water intoxication or fluid overload, which include drowsiness, confusion, headache, listlessness, wheezing, coughing, and tachypnea, to the physician.
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.
After teaching a group of nursing students about drugs that affect the uterus, the instructor determines that the teaching was successful when the students identify which drug as being used for cervical ripening?
- A. Terbutaline
- B. Nifedipine
- C. Dinoprostone
- D. Misoprostol
Correct Answer: C
Rationale: Dinoprostone is a cervical ripening agent, Terbutaline and nifedipine are used for tocolysis. Misoprostol is used as a uterine stimulant.