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A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta.

Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?

A.

The client reports a feeling of vaginal fullness.

B.

The client's fundus is firm and midline.

C.

The client saturates a perineal pad in 1 hr.

D.

The client's umbilical cord lengthens.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.
 


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Related Questions

Correct Answer is A

Explanation

Choice A rationale:
Poor feeding is a common manifestation in newborns of mothers who used methadone during pregnancy.
Choice B rationale:
A weak cry is not specifically associated with methadone use during pregnancy.
Choice C rationale:
An absent Moro reflex is not specifically associated with methadone use during pregnancy.
Choice D rationale:
A respiratory rate of 30/min is within the normal range for a newborn (30-60 breaths per minute) and does not indicate methadone exposure.

Correct Answer is A

Explanation

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

  • Subtract 3 months from June 21, which gives you March 21.
  • Add 7 days to March 21, which gives you March 28.
  • Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

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