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 D
Explanation
Choice A rationale:
Giving oxytocin 20 units IV bolus is incorrect. Oxytocin is used to stimulate uterine contractions, not to stop bleeding.
Choice B rationale:
Performing a fundal massage is incorrect. This is done to stimulate uterine contractions, not to stop bleeding.
Choice C rationale:
Assessing for abdominal tenderness is incorrect. This is not a priority action when a client is exhibiting a large amount of vaginal bleeding.
Choice D rationale:
Obtaining serial hemoglobin and hematocrit is correct. These lab tests will help determine the extent of blood loss and guide treatment.
Correct Answer is B
Explanation
Choice A rationale:
Subcutaneous injections are not typically used for newborns due to their lack of subcutaneous fat.
Choice B rationale:
The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and location.
Choice C rationale:
The deltoid is not a recommended site for IM injections in newborns due to its small size.
Choice D rationale:
As mentioned earlier, subcutaneous injections are not typically used for newborns.
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