A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

Decrease in body temperature.

Maternal cardiac arrhythmias.

Urinary retention.

Insufficient relaxation of the uterus between contractions.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Insufficient relaxation of the uterus between contractions. This is also known as tachysystole or hyperstimulation, which can cause fetal distress and uterine rupture. Oxytocin is a hormone that stimulates uterine contractions, but it can also cause them to be too strong or too frequent if given in high doses or for too long.

Choice A is wrong because oxytocin does not decrease body temperature.

Choice B is wrong because oxytocin does not cause maternal cardiac arrhythmias.

Choice C is wrong because oxytocin does not cause urinary retention.

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Correct Answer is C

Explanation

The correct answer is choice C. Auscultate the fetal heart sounds.This is because spontaneous rupture of membranes (SROM) may be associated with fetal distress or cord prolapse, and the nurse should assess the fetal well-being as soon as possible.Fetal heart sounds can indicate the presence of fetal bradycardia, tachycardia, or decelerations, which may require immediate intervention.

Choice A is wrong because checking the specific gravity of the amniotic fluid is not a priority action after SROM.The specific gravity can help differentiate amniotic fluid from urine, but it is not as reliable as other methods such as nitrazine paper test or visual inspection.

Choice B is wrong because providing dry linens for the patient is a comfort measure, but not a priority action after SROM.The nurse should first ensure the safety of the fetus and the mother before attending to their comfort needs.

Choice D is wrong because notifying the health care provider is an important action after SROM, but not the first one.The nurse should gather relevant data such as fetal heart rate, maternal vital signs, and characteristics of the fluid before contacting the provider.

A. Explain the importance of adequate nutrition for the patient’s own growth and development. B. Explain the relationship between the patient’s eating habits and fetal development. C. Ask what the patient ate and drank within the last day or two. D. Discuss with the patient the basic nutritional requirements of pregnancy.

Correct Answer is C

Explanation

The correct answer is choice C. Ask what the patient ate and drank within the last day or two.This is because the nurse needs to assess the patient’s current nutritional status and eating habits before providing any education or advice.The nurse can then tailor the counseling to the patient’s specific needs and preferences.

Choice A is wrong because it is not the first action that the nurse should take.While it is important to explain the importance of adequate nutrition for the patient’s own growth and development, this should be done after assessing the patient’s current situation.

Choice B is wrong because it is not the first action that the nurse should take.While it is important to explain the relationship between the patient’s eating habits and fetal development, this should be done after assessing the patient’s current situation.

Choice D is wrong because it is not the first action that the nurse should take.While it is important to discuss with the patient the basic nutritional requirements of pregnancy, this should be done after assessing the patient’s current situation.

The normal ranges for nutritional intake during pregnancy vary depending on the age, weight, activity level, and health status of the patient.

However, some general guidelines are:

• Increase calorie intake by about 300 calories per day

• Increase protein intake by about 25 grams per day

• Increase calcium intake by about 1000 milligrams per day

• Increase iron intake by about 27 milligrams per day

• Increase folic acid intake by about 600 micrograms per day

• Increase fluid intake by about 8 to 10 cups per day

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A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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