The priority nursing care associated with an oxytocin (Pitocin) infusion is:
Measuring urinary output.
Evaluating cervical dilation.
Increasing infusion rate every 30 minutes.
Monitoring uterine response.
The Correct Answer is D
Choice A reason:
Measuring urinary output. This is not the priority nursing care associated with an oxytocin infusion, because urinary output is not directly affected by oxytocin. Urinary output may be affected by other factors, such as fluid intake, dehydration, or kidney function, but these are not related to oxytocin administration. • Choice B reason:
Evaluating cervical dilation. This is also not the priority nursing care associated with an oxytocin infusion, because cervical dilation is a result of uterine contractions, not oxytocin itself. Oxytocin is used to stimulate or augment uterine contractions, but it does not cause cervical dilation directly. Cervical dilation is important to monitor during labor, but it is not the main focus of oxytocin infusion. • Choice C reason:
Increasing infusion rate every 30 minutes. This is not the priority nursing care associated with an oxytocin infusion, because increasing the infusion rate every 30 minutes is not a standard protocol for oxytocin administration. The infusion rate should be adjusted according to the patient's response and the provider's orders, but not arbitrarily or routinely. Increasing the infusion rate too quickly or too often can cause hyperstimulation of the uterus, which can be dangerous for both the mother and the fetus.
• Choice D reason:
Monitoring uterine response. This is the correct answer and the priority nursing care associated with an oxytocin infusion, because oxytocin can cause excessive or prolonged uterine contractions, which can lead to fetal distress, uterine rupture, or placental abruption. Therefore, the nurse must monitor the frequency, duration, and intensity of uterine contractions, as well as the fetal heart rate and blood pressure, to ensure that oxytocin is having the desired effect and not causing any adverse outcomes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Basal metabolic rate reduction. This is incorrect because a newborn under a radiant heat warmer will have an increased basal metabolic rate, not a reduced one. The basal metabolic rate is the amount of energy the body uses at rest, and it is influenced by temperature. A warmer environment will stimulate the newborn's metabolism and increase the energy expenditure. • Choice B reason:
Brown fat production. This is incorrect because a newborn under a radiant heat warmer will have less need for brown fat production, not more. Brown fat is a type of fat tissue that generates heat by burning calories. It is found in newborns and helps them maintain their body temperature in cold environments. A warmer environment will reduce the need for brown fat activation. • Choice C reason:
Shivering. This is incorrect because a newborn under a radiant heat warmer will not shiver, but shivering is not the main mechanism of heat production in newborns. Shivering is an involuntary contraction of muscles that generates heat by increasing metabolism. Newborns have limited ability to shiver because of their immature nervous system and low muscle mass. They rely more on brown fat and increased metabolic rate to produce heat. • Choice D reason:
Cold stress. This is correct because a newborn under a radiant heat warmer will prevent cold stress, which is a condition where the newborn's body temperature drops below normal and causes adverse effects. Cold stress can impair oxygen delivery, increase acidosis, decrease blood glucose, and increase the risk of infection and bleeding. A radiant heat warmer provides a neutral thermal environment for the newborn and prevents heat loss by radiation.
: 1 : 2 : 3 : 4.
Correct Answer is C
Explanation
Choice A reason:
While positioning is important for comfort during labor, addressing the immediate urge to push takes priority. Panting during contractions is the appropriate action.
Choice B reason:
Although observing for crowning is important when the client is close to delivery, the nurse should first intervene to address the client's urge to push since the client is only 7 cm dilated.
Choice C reason:
When a laboring client feels the urge to push but is not yet fully dilated (10 cm), encouraging her to pant can help reduce the urge to push and avoid complications, such as cervical swelling or tearing. This breathing technique helps the client delay pushing until full dilation and readiness of the cervix.
Choice D reason:
Assisting the client to the bathroom would not be appropriate at this stage of labor because the urge to push could lead to unsafe delivery outside the appropriate setting, and movement could increase discomfort or risks.
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