A nurse is assessing a client who received methylergonovine to treat uterine atony in the fourth stage of labor.
Which of the following findings should the nurse identify as an adverse effect of the medication?

Seizures.

Hypertension.

Tachycardia.

Water retention.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While seizures are a serious adverse effect of ergot alkaloids, they are primarily associated with the most severe form of ergotism, which is an overdose or prolonged exposure, or in clients with severe preeclampsia/eclampsia. Methylergonovine's more common and immediate adverse effect is its potent vasoconstrictive property, leading to elevated blood pressure.

Choice B rationale

Methylergonovine is an ergot alkaloid that acts as a potent vasoconstrictor and smooth muscle contractor, primarily on the uterus to treat postpartum hemorrhage and uterine atony. Its generalized vasoconstrictive effect, however, can lead to a significant elevation in blood pressure, making hypertension (blood pressure greater than 140/90 mmHg or an increase of 20 mmHg or more) a major and frequent adverse effect.

Choice C rationale

Methylergonovine's potent vasoconstrictive action typically causes an increase in peripheral vascular resistance, which often results in bradycardia (heart rate less than 60 beats/min) as a reflex response to the elevated blood pressure. Tachycardia (heart rate greater than 100 beats/min) is not a typical adverse effect of this medication.

Choice D rationale

Methylergonovine acts mainly on the smooth muscle of the uterus and blood vessels; it does not typically cause water retention. Water retention is more commonly associated with conditions like preeclampsia or medications such as glucocorticoids. The adverse effects of methylergonovine center around vasoconstriction and uterine cramping.

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Correct Answer is C

Explanation

Choice A rationale: Trendelenburg position, where the client is placed with the head lower than the feet, is not appropriate in this scenario. This position is typically used for procedures requiring pelvic exposure or in cases of air embolism. It does not optimize uteroplacental perfusion and may actually compromise maternal respiratory function in late pregnancy due to diaphragmatic pressure from the gravid uterus. Therefore, it is not the correct position following prostaglandin insertion.

Choice B rationale: Knee-chest position is used in obstetric emergencies such as umbilical cord prolapse to relieve pressure on the cord and improve fetal oxygenation. It is not indicated for cervical ripening or for optimizing uteroplacental perfusion. Maintaining this position would be uncomfortable and unnecessary for the client, and it does not aid in medication absorption. Thus, it is not the correct intervention in this context.

Choice C rationale: Lateral tilt, specifically left lateral or side-lying tilt, is the correct position. This position reduces compression of the inferior vena cava by the gravid uterus, thereby improving venous return, cardiac output, and uteroplacental perfusion. It also facilitates optimal absorption of the vaginal prostaglandin insert by keeping the medication in place. This is the evidence-based nursing intervention following prostaglandin administration for cervical ripening.

Choice D rationale: Lithotomy position is used primarily for vaginal examinations, procedures, or delivery. It is not appropriate for maintaining medication absorption or optimizing uteroplacental perfusion. Prolonged lithotomy positioning increases maternal discomfort and risk of venous stasis. Since the client is not undergoing delivery or a procedure requiring pelvic exposure, this position is not indicated after prostaglandin insertion.

A. Ask the client about the color of the fluid. B. Determine the fetal heart rate. C. Monitor cervical dilation. D. Obtain the client's vaginal pH.

Correct Answer is B

Explanation

Choice A rationale

Asking about the fluid's color (clear, meconium-stained, bloody) provides information about fetal well-being and potential complications (like meconium aspiration), but it is a secondary assessment. While important, it does not supersede the need to immediately assess the most urgent physiological parameter of fetal status, which is the heart rate.

Choice B rationale

The rupture of membranes (water breaking) carries a risk of prolapsed umbilical cord, which can severely compromise fetal oxygenation by compressing the umbilical vessels. Determining the fetal heart rate (FHR) immediately is the priority action to identify signs of fetal distress, such as bradycardia (FHR <110 beats/min), indicating cord compression. The normal FHR range is 110-160 beats/min.

Choice C rationale

Monitoring cervical dilation is necessary to determine the stage and progress of labor. However, in the setting of ruptured membranes, assessing the immediate safety and stability of the fetus takes precedence over checking labor progress. A vaginal exam to check dilation is done after assessing FHR and ruling out immediate emergencies like cord prolapse.

Choice D rationale

Determining the vaginal pH with Nitrazine paper can confirm if the fluid is amniotic fluid (alkaline, pH 7.0-7.5) or urine/vaginal secretions (acidic). While this confirms the rupture of membranes, establishing the status of the fetus by assessing the FHR is the most critical and life-saving priority action to take first to prevent or quickly address fetal hypoxia.

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A nurse is assessing a client who received methylergonovine to treat uterine atony in the fourth stage of labor. Which of the following findings should the nurse identify as an adverse effect of the medication?

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Correct Answer is C

Explanation

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Correct Answer is B

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A nurse is assessing a client who received methylergonovine to treat uterine atony in the fourth stage of labor.
Which of the following findings should the nurse identify as an adverse effect of the medication?