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 B
Explanation
Choice A rationale:
The amount of amniotic fluid around the fetus is determined by an ultrasound, not an indirect Coombs’ test.
Choice B rationale:
The indirect Coombs’ test is used to detect Rh-positive antibodies in the mother’s blood.
Choice C rationale:
The risk of hypoglycemia in the newborn is not determined by the indirect Coombs’ test.
Choice D rationale:
Blood flow in the fetus and placenta is studied using Doppler ultrasound, not an indirect Coombs’ test.
Correct Answer is A
Explanation
Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.
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