Nokea
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.
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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.
The nurse is preparing to administer a prescribed drug to help prevent hemorrhage caused by uterine atony. Which drug would the nurse most likely administer?
- A. Carboprost (Hemabate)
- B. Indomethacin (Indocin)
- C. Methylergonovine (Methergine)
- D. Terbutaline (Brethine)
- E. Misoprostol (Cytotec)
Correct Answer: A,C,E
Rationale: Carboprost (Hemabate), methylergonovine (Methergine), misoprostol (Cytotec), and ergonovine (Ergotrate) are used postpartum to prevent hemorrhage caused by uterine atony. Indomethacin and terbutaline are used as tocolytics.
A client is receiving methylergonovine (Methergine). After administering the drug, the nurse would be alert for which of the following?
- A. Chest pain
- B. Hypoglycemia
- C. Increase in blood pressure
- D. Diarrhea
- E. Water intoxication
Correct Answer: A,C,D
Rationale: Adverse reactions associated with methylergonovine include temporary chest pain, hypertension, diarrhea, nausea, vomiting, dizziness, and headache.
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.
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.