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:
10% to 15% of their birth weight. This is incorrect because this range is too high for a normal newborn weight loss. Losing more than 10% of their birth weight may indicate dehydration, inadequate feeding, or other problems. • Choice B reason:
20% of their birth weight. This is incorrect because this percentage is way too high for a normal newborn weight loss. Losing 20% of their birth weight would be a serious sign of illness or malnutrition. • Choice C reason:
15% to 18% of their birth weight. This is incorrect because this range is also too high for a normal newborn weight loss. Losing 15% to 18% of their birth weight would be a cause for concern and require further evaluation. • Choice D reason:
5% to 10% of their birth weight. This is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight as a result of insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth. They usually regain their birth weight by the second week.
Correct Answer is D
Explanation
The correct answer is: d. Move infant away from blowing fan.
Choice A: Dry the baby after a bath
Drying the baby after a bath is essential to prevent heat loss through evaporation. When a newborn is wet, the water on their skin can evaporate, taking heat away from their body. While this is an important step in maintaining the baby’s temperature, it does not specifically address heat loss through convection.
Choice B: Wrap the baby in warmed blankets
Wrapping the baby in warmed blankets helps prevent heat loss through conduction and radiation. Conduction occurs when the baby comes into contact with a cooler surface, and radiation occurs when the baby loses heat to the surrounding environment. Although this action is beneficial, it does not directly address heat loss through convection.
Choice C: Place the baby in a warmer
Placing the baby in a warmer is an effective way to maintain the baby’s overall body temperature by providing a controlled, warm environment. This action helps prevent heat loss through conduction, radiation, and evaporation. However, it is not the most direct method to prevent heat loss through convection.
Choice D: Move infant away from blowing fan
Moving the infant away from a blowing fan directly addresses and prevents heat loss due to air movement, which is a key factor in convection. Convection occurs when air currents carry heat away from the baby’s body. By moving the baby away from the fan, the nurse can effectively reduce heat loss through this mechanism.
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