A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate the effectiveness of this medication?
Urinary output.
Fundal consistency.
Pulse rate.
Blood pressure.
The Correct Answer is B
Choice A rationale:
The nurse should monitor the urinary output of the client as it can be an important indicator of hydration and renal function. However, in this specific scenario, the administration of oxytocin via IV infusion after a vaginal delivery requires a different focus for evaluating medication effectiveness.
Choice B rationale:
The nurse should primarily assess the fundal consistency to evaluate the effectiveness of oxytocin. Oxytocin is often administered after childbirth to promote uterine contractions and prevent postpartum hemorrhage. Checking the fundal consistency helps determine if the uterus is contracting appropriately. A firm fundus indicates effective contractions, which are essential for controlling bleeding and preventing complications.
Choice C rationale:
Monitoring the pulse rate is a vital aspect of patient care, but it may not be the most relevant parameter to evaluate the effectiveness of oxytocin. Pulse rate can give information about the client's cardiovascular status and general well-being, but it does not directly assess the medication's impact on uterine contractions.
Choice D rationale:
Similarly, keeping an eye on blood pressure is crucial for patient safety and detecting potential issues like hypertension. However, it is not the primary parameter for evaluating the effectiveness of oxytocin. Blood pressure monitoring is essential for overall health assessment but does not directly relate to the medication's intended effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
The Apgar s core is a s coring s ys tem doctors and nurs es us e to as s es s newborns after they’re born. The Apgar s coring s ys tem is divided into five categories : Activity, Puls e, Grimace, Appearance, and Res piration. Each category receives a s core of 0 to 2 points 1.
Bas ed on the information you provided, the newborn’s 1-min Apgar s core would be calculated as follows :
• Activity: s ome flexion of extremities = 1 point
• Puls e: heart rate 110/ min = 2 points
• Grimace: grimace in res pons e to s uctioning of the nares = 1 point
• Appearance: body pink in color with blue extremities = 1 point
• Res piration: s low, weak cry = 1 point
Adding up the points for each category, the newborn’s 1-min Apgar s core would be 6.
Correct Answer is B
Explanation
Choice A rationale:
Stimulate the infant to cry. While stimulating the infant to cry is a common practice to assess the newborn's respiratory function, it is not the first action the nurse should perform in this situation. The newborn may cry spontaneously or may require other interventions, such as clearing the respiratory tract, before crying.
Choice B rationale:
Clear the respiratory tract. Clearing the respiratory tract is the priority action in this scenario. It ensures that the airway is open and allows the infant to breathe effectively. This is crucial because newborns are at higher risk of respiratory distress after birth, and prompt action can prevent complications.
Choice C rationale:
Dry the infant off and cover the head. Drying the infant off and covering the head are important steps to prevent heat loss and maintain the newborn's body temperature. However, these actions can be delayed briefly until the respiratory tract is cleared, as the immediate focus should be on ensuring the infant's ability to breathe.
Choice D rationale:
Clamp the umbilical cord. Clamping the umbilical cord is a standard procedure after birth to prevent bleeding and infection. However, it is not the priority in this situation. The first step should be to ensure the newborn's airway is clear and they can breathe adequately.
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