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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Related Questions
Correct Answer is A
Explanation
Choice A reason:
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it causes a reduction of placental blood flow. Placental blood flow is essential for delivering oxygen and nutrients to the fetus and removing waste products. Hypertonic contractions are too frequent, too long, or too strong, and they can reduce the time for the placenta to refill with blood between contractions. This can lead to fetal hypoxia, acidosis, and distress.
Choice B reason:
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it produces a prolapsed cord. This is incorrect because a prolapsed cord is not caused by hypertonic contractions, but by other factors such as a low-lying placenta, a premature rupture of membranes, a small or preterm fetus, or an abnormal presentation. A prolapsed cord occurs when the umbilical cord slips through the cervix and into the vagina before or during delivery. This can compress the cord and cut off the blood supply to the fetus, resulting in fetal bradycardia and possible death.
Choice C reason:
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it increases maternal renal blood flow. This is incorrect because hypertonic contractions do not affect maternal renal blood flow directly. Maternal renal blood flow is influenced by factors such as maternal blood pressure, hydration, cardiac output, and renal function. Hypertonic contractions may cause maternal dehydration, which can reduce renal blood flow, but this is not a direct effect of oxytocin stimulation.
Choice D reason:
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it decreases maternal blood pressure. This is incorrect because hypertonic contractions do not cause maternal hypotension, but rather hypertension. Hypertension is a common side effect of oxytocin stimulation, as oxytocin causes vasoconstriction and increases the sensitivity of the vascular smooth muscle to catecholamines. Hypertension can lead to complications such as preeclampsia, eclampsia, and placental abruption.
Correct Answer is []
Explanation
The diagram should be completed as follows:
Condition Most Likely Experiencing: B. Respiratory distress syndrome. Action to Take 1: C. Administer Surfactant as prescribed. Action to Take 2: Provide oxygen therapy as needed. Parameter to Monitor 1: B. Arterial blood gases. Parameter to Monitor 2: D. Oxygen saturation.
Conditions Explained
Choice A reason:
Hypoglycemia is a condition where the blood glucose level is too low. It can cause symptoms
such as jitteriness, lethargy, poor feeding, and seizures. However, hypoglycemia does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of hypoglycemia. Therefore,
choice A is incorrect.
Choice B reason:
Respiratory distress syndrome (RDS) is a condition where the lungs are not fully developed
and lack enough surfactant, a substance that helps the alveoli stay open and exchange
oxygen and carbon dioxide. It can cause symptoms such as tachypnea, grunting, nasal flaring,
retractions, and cyanosis. RDS is more common in premature infants, especially those born
before 37 weeks of gestation. Acrocyanosis can be a normal finding in the first 24 hours of
life, but it can also indicate poor perfusion due to respiratory compromise. Therefore, choice
B is the most likely condition that the newborn is experiencing.
Choice C reason:
Neonatal abstinence syndrome (NAS) is a condition where the newborn withdraws from
drugs that were exposed in utero. It can cause symptoms such as irritability, tremors, high-
pitched crying, poor feeding, vomiting, diarrhea, and sweating. However, NAS does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of NAS. Therefore, choice C is
incorrect.
Choice D reason:
Jaundice is a condition where the skin and sclerae turn yellow due to excess bilirubin in the
blood. It can be caused by various factors such as blood group incompatibility, hemolysis,
infection, or liver dysfunction. However, jaundice does not explain the respiratory signs that
the newborn is experiencing, such as tachypnea, grunting, nasal flaring, and retractions.
Acrocyanosis is also not a sign of jaundice.
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