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?
The client reports a feeling of vaginal fullness.
The client's fundus is firm and midline.
The client saturates a perineal pad in 1 hr.
The client's umbilical cord lengthens.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.
Correct Answer is B
Explanation
Choice A rationale:
Hypertension is not a typical symptom of abruptio placentae.
Choice B rationale:
Uterine tenderness is a common symptom of abruptio placentae.
Choice C rationale:
Fetal tachycardia is not a typical symptom of abruptio placentae.
Choice D rationale:
Leukorrhea is not associated with abruptio placentae.
The most likely finding the nurse should expect in a client experiencing abruptio placenta during labor is:
b. Uterine tenderness.
Here's why:
- Hypertension (a):While preeclampsia can increase the risk of abruptio placenta,it's not always present,and hypertension wouldn't be the immediate expected finding during the abruption event itself.
- Fetal tachycardia (c):This can occur in early stages of abruption to compensate for decreased oxygen supply,but as the abruption becomes more severe,fetal bradycardia is more likely due to oxygen deprivation.
- Leukorrhea (d):This is a white vaginal discharge and has no connection to abruptio placenta.
Uterine tenderness is a characteristic sign of abruptio placenta due to bleeding behind the placenta and irritation of the uterine muscle. This is often accompanied by:
- Vaginal bleeding (bright red or dark)
- Abdominal pain or cramping
- Sudden, ongoing uterine tightening or irritability
- Fetal distress (decreased fetal heart rate movements)
Therefore, option b is the most expected finding in this scenario.
Remember: Early recognition and prompt management of abruptio placenta are crucial for optimal outcomes for both mother and baby. If you suspect abruptio placenta, immediate medical attention is essential.
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