Nokea
After administering an injection of oxytocin (Pitocin), the nurse continues to assess which of the following?
- A. Blood pressure
- B. Blood glucose
- C. Pulse
- D. Temperature
- E. Respiratory rate
Correct Answer: A,C,E
Rationale: After an injection of oxytocin (Pitocin), during ongoing assessment the nurse monitors the following: the client's blood pressure, pulse, and respiratory rate.
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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.
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.
Before beginning an IV infusion of oxytocin (Pitocin) to induce labor, the nurse obtains an obstetric history that includes which of the following?
- A. Parity
- B. Stillbirths
- C. Abortions
- D. Previous obstetric problems
- E. Type of labor
Correct Answer: A,B,C,D,E
Rationale: Before beginning an IV infusion of oxytocin (Pitocin) to induce labor, the nurse obtains an obstetric history that includes parity, gravidity, previous obstetric problems, type of labor, stillbirths, abortions, and live-birth infant abnormalities.
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 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.