A nurse administers oxytocin IV after delivery to a client with postpartum hemorrhage. Which assessment best indicates that the oxytocin is effective?
The client’s blood pressure increases.
The amount of lochia rubra increases.
The client reports relief of afterpains.
The uterus is firm on palpation.
The Correct Answer is D
Choice A reason: An increase in blood pressure is not a direct indicator of oxytocin’s effectiveness. Blood pressure changes may occur due to fluid shifts or vasoconstriction, but they do not confirm control of hemorrhage.
Choice B reason: An increase in lochia rubra would actually suggest worsening bleeding rather than improvement. Oxytocin should reduce blood loss by contracting the uterus, not increase it.
Choice C reason: Relief of afterpains is subjective and not a reliable measure of oxytocin’s effectiveness. Oxytocin often increases afterpains due to uterine contractions, so this is not a valid indicator.
Choice D reason: A firm uterus on palpation is the best indicator of oxytocin effectiveness. Oxytocin stimulates uterine smooth muscle contraction, which compresses blood vessels at the placental site, reducing hemorrhage. A firm uterus means bleeding is controlled.
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Correct Answer is C
Explanation
Choice A reason: Administering the highest effective dose is unsafe. Oxytocin must be titrated carefully because excessive dosing can cause uterine tachysystole, fetal distress, or uterine rupture.
Choice B reason: Intermittent monitoring is not appropriate with oxytocin infusion. Continuous monitoring is required because oxytocin increases risk of fetal compromise and uterine hyperstimulation.
Choice C reason: Administering the dose as ordered is the correct consideration. Nurses must follow prescribed protocols, titrate carefully, and monitor maternal-fetal response. This ensures safe induction while minimizing risks.
Choice D reason: Discontinuing oxytocin for reassuring fetal heart patterns is incorrect. Oxytocin should be discontinued if fetal heart patterns become non-reassuring or if uterine tachysystole occurs, not when patterns are reassuring.
Correct Answer is C
Explanation
Choice A reason: Changing sanitary pads only when completely saturated is unsafe. Saturated pads increase the risk of infection because bacteria thrive in moist environments. Additionally, waiting until pads are fully soaked can delay recognition of excessive bleeding or postpartum hemorrhage.
Choice B reason: Changing sanitary pads only twice per day is inadequate. Postpartum women should change pads frequently, at least every few hours, to maintain hygiene and reduce infection risk. This practice also allows monitoring of lochia flow and early detection of abnormal bleeding.
Choice C reason: Cleansing from the periurethral area to the perineal area is the correct technique. This front-to-back cleansing prevents the transfer of bacteria from the rectal area to the urethra and vagina, reducing the risk of urinary tract infections and endometritis. Proper perineal hygiene is essential in preventing postpartum complications.
Choice D reason: Vigorous wiping is contraindicated. It can cause trauma to the perineum, especially if there are lacerations, episiotomy sites, or hemorrhoids. Gentle cleansing is recommended to avoid irritation and promote healing.
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