A client is receiving (Pitocin) oxytocin to induce labor. The nurse should monitor for which of the following adverse maternal effects?

Jaundice

Dehydration

Uterine hyperstimulation.

Maternal bradycardia

Answer and Explanation

The Correct Answer is C

A. Jaundice. Oxytocin does not cause jaundice in the mother. Jaundice is typically related to liver dysfunction, hemolysis, or bile obstruction and is not an expected side effect of oxytocin administration.

B. Dehydration. While prolonged labor induction may contribute to dehydration if fluid intake is insufficient, oxytocin itself does not directly cause dehydration. IV fluids are typically administered alongside oxytocin to maintain hydration during labor.

C. Uterine hyperstimulation. Uterine hyperstimulation (tachysystole), defined as more than five contractions in 10 minutes, is a serious complication of oxytocin administration. It can lead to fetal distress, uterine rupture, and impaired placental perfusion. If hyperstimulation occurs, the nurse should discontinue oxytocin, reposition the patient, provide oxygen, and notify the provider.

D. Maternal bradycardia. Oxytocin does not typically cause bradycardia. Maternal side effects are more commonly tachycardia, hypertension, or fluid retention. Fetal bradycardia, however, can occur if uterine hyperstimulation leads to fetal hypoxia.

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Correct Answer is ["A","D","E"]

Explanation

A. Right-sided epigastric pain. Epigastric pain, especially on the right side, is a concerning sign of preeclampsia and may indicate liver involvement due to elevated liver enzymes or HELLP syndrome. This symptom should be assessed further as it suggests worsening disease progression.

B. Uterine contractions. Uterine contractions are not a defining feature of preeclampsia. They are more commonly associated with preterm labor rather than hypertension-related complications. While preeclampsia can lead to preterm birth, contractions alone do not confirm or negate the condition.

C. Bright red painless vaginal bleeding. Bright red painless vaginal bleeding is more indicative of placenta previa or another obstetric complication rather than preeclampsia. Preeclampsia primarily presents with hypertension, proteinuria, and systemic symptoms rather than vaginal bleeding.

D. Severe headache. A severe headache is a classic symptom of preeclampsia, often due to elevated blood pressure and cerebral edema. Persistent headaches that do not resolve with usual interventions should be evaluated promptly as they may indicate worsening hypertension or an impending seizure.

E. Visual disturbances. Visual disturbances such as blurred vision, photophobia, or seeing spots are common in preeclampsia and can signal cerebral edema or increased intracranial pressure. This is a significant warning sign requiring immediate assessment.

F. Dull backache. A dull backache is more commonly associated with musculoskeletal strain, labor, or a urinary tract infection rather than preeclampsia. While discomfort can be present in pregnancy, it is not a defining symptom of preeclampsia.

A. Stay with the patient and call for help B. Suction the mouth to prevent aspiration C. Insert an oral airway D. Administer oxygen by tight face mask

Correct Answer is A

Explanation

A. Stay with the patient and call for help. The priority during a seizure is to ensure the patient’s safety and call for immediate assistance. The nurse should stay with the patient, protect her from injury, and note the seizure’s duration and characteristics. After the seizure ends, further interventions can be implemented.

B. Suction the mouth to prevent aspiration. Suctioning should only be performed after the seizure ends. Attempting to suction during an active seizure increases the risk of injury and airway obstruction.

C. Insert an oral airway. Inserting an oral airway during an active seizure is unsafe and contraindicated because it may cause trauma to the mouth or airway. An airway can be inserted after the seizure stops if necessary.

D. Administer oxygen by tight face mask. While oxygen is important, it should be provided after the seizure subsides and the airway is assessed. The primary focus during the seizure is safety, preventing injury, and calling for emergency assistance.

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A client is receiving (Pitocin) oxytocin to induce labor. The nurse should monitor for which of the following adverse maternal effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primigravida who is 28 weeks pregnant visits the clinic fearing she is experiencing preeclampsia. Which of the following assessments would the nurse make to confirm or negate these thoughts? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to:

Correct Answer is A

Explanation

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