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 C
Explanation
Choice A reason:
While hypoglycemia (glucose <45 mg/dL) is concerning,58 mg/dLis within acceptable ranges for many institutions, especially in asymptomatic newborns. Monitoring is required, but it is less urgent than respiratory distress.
Choice B reason:
Respiratory rate of 78 breaths per minute is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute. Though respiratory rate is essential to assess, it does not take priority over other critical issues.
Choice C reason:
Newborns typically have a normal respiratory rate of30-60 breaths/minute. A rate of78indicatessignificant tachypnea, which could signal respiratory distress (e.g., transient tachypnea of the newborn, infection, or respiratory distress syndrome). Rapid breathing can lead to fatigue, hypoxia, or respiratory failure if not promptly addressed.
Choice D reason:
A glucose reading of 58 mg/dL is concerning in a newborn. Hypoglycemia (low blood glucose) can lead to serious complications if not promptly addressed. Newborns are particularly susceptible to hypoglycemia, and it requires immediate assessment and intervention.
Correct Answer is B
Explanation
Choice A reason:
If the client reports frequent uterine contractions , it is not indicative of a distended bladder. Postpartum uterine contractions are normal and necessary to help the uterus return to its pre-pregnancy size.
Choice B reason:
The fundus (the top portion of the uterus being palpable to the right of the midline suggests a distended bladder. A full bladder can displace the uterus, causing the fundus to deviate from the midline.
Choice C reason:
Having less than 2.5 cm of rubra lochia on a perineal pad is related to the amount of vaginal discharge after birth and does not provide information about bladder distention.
Choice D reason:
The client's report of increased thirst may indicate dehydration or the body's response to fluid loss during childbirth but is not directly related to bladder distention.
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