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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice C rationale:

This response is correct because black stools are a common side effect of taking iron supplements. Iron can cause the stool to appear black or

tarry due to the way it is broken down during digestion. It does not necessarily indicate a serious issue, especially if the client is not experiencing any abdominal pain or cramping. Educating the client about this expected side effect helps alleviate any concerns they might have about the change in stool colour.

Choice A rationale:

"Go to the emergency room and your provider will meet you there.”. This response is not appropriate in this situation. The client's report of black stools without abdominal pain or cramping is likely due to the iron supplements and does not warrant a visit to the emergency room. This response may cause unnecessary panic and anxiety for the client.

Choice B rationale:

"What else have you been eating?.”. This response is also not the best choice. While it's essential for healthcare providers to gather comprehensive information about a client's diet and lifestyle, in this case, the client's black stools can be directly attributed to the iron supplements. Focusing on other dietary factors might distract from addressing the client's concern about the side effect of iron supplementation.

Choice D rationale:

"Come to the office, and we will check things out.”. This response is not the most appropriate one either. A visit to the office might not be necessary solely based on the client's report of black stools without accompanying pain or cramping. This situation can be managed through education, and the client can be reassured that it is a typical side effect of iron supplements. An unnecessary visit to the office could inconvenience the client and waste both their time and the healthcare provider's time.

A. Fetal heart rate 100/min for a 10-min period. B. Contraction resting period 35 seconds. C. Contraction lasting 85 seconds. D. Four contractions in a 10-min period.

Correct Answer is C

Explanation

Choice A rationale:

A fetal heart rate of 100/min for a 10-minute period is considered within the normal range. The normal fetal heart rate can range from 110 to 160 beats per minute, and a rate of 100 is not concerning.

Choice B rationale:

The resting period of a contraction refers to the time between contractions when the uterus is relaxed. A resting period of 35 seconds is also considered normal. In labor, the resting period between contractions allows the placenta to receive oxygen and nutrients, and 35 seconds is a rationaleable duration.

Choice C rationale:

A contraction lasting 85 seconds is abnormal and should be reported to the provider. Normally, contractions last around 60-90 seconds, but an 85-second contraction may indicate uterine hyperactivity or other issues that could potentially affect the well-being of both the mother and the baby.

Choice D rationale:

Having four contractions in a 10-minute period is considered normal during labor. In fact, an average pattern includes 3-5 contractions within a 10-minute window, so this finding is not a cause for concern.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking on the phone to a client who is pregnant and taking iron supplements for iron-deficiency anaemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is in labour. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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