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 A
Explanation
The correct answer is: a. Hyperbilirubinemia.
Choice A: Hyperbilirubinemia
Reason: Hyperbilirubinemia in newborns is often caused by the increased breakdown of red blood cells, which have a shorter lifespan in neonates. This breakdown produces bilirubin, a yellow pigment that can accumulate in the blood, leading to jaundice. The liver of a newborn is not fully mature and may not be able to process and excrete bilirubin efficiently, resulting in hyperbilirubinemia.
Choice B: Respiratory Distress Syndrome
Reason: Respiratory Distress Syndrome (RDS) is primarily caused by a deficiency of surfactant in the lungs, which is more common in premature infants. It is not directly related to the lifespan of red blood cells. Symptoms include rapid, shallow breathing and a bluish color due to lack of oxygen.
Choice C: Polycythemia
Reason: Polycythemia is characterized by an abnormally high concentration of red blood cells. It is often due to factors like delayed cord clamping or maternal diabetes, rather than the decreased lifespan of red blood cells. Polycythemia can lead to increased blood viscosity and complications such as sluggish blood flow.
Choice D: Transient Tachypnea
Reason: Transient Tachypnea of the Newborn (TTN) is a respiratory condition caused by delayed clearance of fetal lung fluid. It typically resolves within a few days and is not related to the lifespan of red blood cells. Symptoms include rapid breathing and grunting.
Correct Answer is A
Explanation
Choice A reason:
Babinski's Reflex is the normal response in infants when the sole of the foot is stroked from the heel to the ball of the foot. The big toe moves upward or toward the top surface of the foot, and the other toes fan out. This reflex is normal in children up to 2 years old, and it disappears as the nervous system matures. It may indicate damage to the central nervous system in older children and adults.
Choice B reason:
Stepping Reflex is the normal response in infants when they are held upright with their feet touching a flat surface. They will lift one foot and then the other, as if they are walking. This reflex is present at birth and lasts for about 2 months. It helps prepare the infant for voluntary walking.
Choice C reason:
Moro Reflex is the normal response in infants when they are startled by a loud noise or a sudden movement. They will extend their arms and legs, open their hands, and then curl up and bring their arms together as if they are hugging themselves. This reflex is present at birth and lasts for about 4 to 6 months. It is thought to be a protective response that helps the infant cling to their caregiver.
Choice D reason:
Plantar Grasp Reflex is the normal response in infants when pressure is applied to the sole of the foot near the toes. The toes will curl down and grasp the stimulus. This reflex is present at birth and lasts for about 9 to 12 months. It is similar to the palmar grasp reflex in the hands, and it helps develop the muscles and nerves in the feet. Some additional sentences are:. If you are interested in learning more about infant development, you can check out some of these links:. • [A guide to newborn reflexes]. • [A video demonstration of newborn reflexes].
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