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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason:

Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.

Choice B reason:

Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.

Choice C reason:

Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.

Choice D reason:

Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.

A. Uteroplacental insufficiency. B. Umbilical cord compression. C. Maternal bradycardia. D. Fetal head compression.

Correct Answer is A

Explanation

Choice A reason:

Uteroplacental insufficiency is a condition where the placenta cannot deliver enough oxygen and nutrients to the fetus. This can cause fetal hypoxia and distress, which can be detected by late decelerations on the fetal heart rate monitor. Late decelerations are defined as a decrease in the fetal heart rate that begins after the peak of the contraction and returns to baseline after the contraction ends. This indicates that the fetus is not tolerating the reduced blood flow during the contractions and needs immediate intervention. • Choice B reason:

Umbilical cord compression is a condition where the umbilical cord is squeezed or twisted, reducing the blood flow and oxygen to the fetus. This can cause variable decelerations on the fetal heart rate monitor. Variable decelerations are defined as a decrease in the fetal heart rate that varies in timing, shape, and duration, and may or may not be associated with contractions. This indicates that the fetus is experiencing intermittent or sustained cord compression and may need repositioning or other interventions. • Choice C reason:

Maternal bradycardia is a condition where the mother's heart rate is slower than normal, usually less than 60 beats per minute. This can cause reduced blood flow and oxygen to the placenta and the fetus, but it does not cause late decelerations on the fetal heart rate monitor. Maternal bradycardia can be caused by various factors, such as medications, hypothermia, hypothyroidism, or vagal stimulation. It may need treatment depending on the cause and severity. • Choice D reason:

Fetal head compression is a condition where the fetal head is pressed against the cervix or the pelvic floor during labor, stimulating the vagus nerve and slowing down the fetal heart rate. This can cause early decelerations on the fetal heart rate monitor. Early decelerations are defined as a decrease in the fetal heart rate that begins with the onset of the contraction and returns to baseline with the end of the contraction. This indicates that the fetus is descending in the birth canal and is usually a normal and benign finding.

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The priority nursing care associated with an oxytocin (Pitocin) infusion is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer is A

Explanation

A nurse receives handoff report. Which newborn should the nurse assess first?

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The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?

Which maternal event is abnormal in the early postpartum period?

A client in latent phase of labor for the past 12 hours is requesting medication to help her rest.

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?