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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Lochial color changes from rubra to alba in the early postpartum period is a normal event. Lochia is the vaginal discharge that occurs after childbirth, and it progresses from bright red (rubra) to pink or brownish (serosa) to whitish-yellow (alba) as the days pass.
Choice B reason:
Extreme hunger and thirst in the early postpartum period may indicate abnormal blood sugar levels and can be a sign of gestational diabetes or other metabolic disorders. It requires further evaluation and monitoring by healthcare providers.
Choice C reason:
Diuresis (increased urination) and diaphoresis (increased sweating) are normal events in the early postpartum period. After childbirth, the body eliminates excess fluid that was retained during pregnancy, leading to increased urination and sweating.
Choice D reason:
Flatulence (passing gas) and constipation can be normal events in the early postpartum period due to the body recovering from the effects of labor, changes in diet, and the use of pain medications during childbirth.
Correct Answer is D
Explanation
The correct answer is choice D. Announcement of the delivery.
Choice A reason:
Support thermoregulation is a priority in nursing care of the newborn immediately after birth. Newborns are at risk of hypothermia because they have a large surface area to body mass ratio, thin skin, and limited subcutaneous fat. To prevent heat loss, newborns should be dried thoroughly, placed skin-to-skin with the mother, and covered with warm blankets.
Choice B reason:
Identifying the infant is a priority nursing care of the newborn immediately after birth. Newborns should be identified with identification bands that match those of the mother and father or significant other. This helps prevent errors in infant identification and ensures safety and security.
Choice C reason:
Promoting normal respirations is a priority nursing care of the newborn immediately after birth. Newborns need to establish effective breathing patterns to ensure adequate oxygenation and prevent complications such as respiratory distress syndrome or meconium aspiration syndrome. To promote normal respirations, newborns should be suctioned gently to clear the airway, stimulated to cry, and assessed for signs of distress.
Choice D reason:
Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
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