A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate the effectiveness of this medication?
Urinary output.
Fundal consistency.
Pulse rate.
Blood pressure.
The Correct Answer is B
Choice A rationale:
The nurse should monitor the urinary output of the client as it can be an important indicator of hydration and renal function. However, in this specific scenario, the administration of oxytocin via IV infusion after a vaginal delivery requires a different focus for evaluating medication effectiveness.
Choice B rationale:
The nurse should primarily assess the fundal consistency to evaluate the effectiveness of oxytocin. Oxytocin is often administered after childbirth to promote uterine contractions and prevent postpartum hemorrhage. Checking the fundal consistency helps determine if the uterus is contracting appropriately. A firm fundus indicates effective contractions, which are essential for controlling bleeding and preventing complications.
Choice C rationale:
Monitoring the pulse rate is a vital aspect of patient care, but it may not be the most relevant parameter to evaluate the effectiveness of oxytocin. Pulse rate can give information about the client's cardiovascular status and general well-being, but it does not directly assess the medication's impact on uterine contractions.
Choice D rationale:
Similarly, keeping an eye on blood pressure is crucial for patient safety and detecting potential issues like hypertension. However, it is not the primary parameter for evaluating the effectiveness of oxytocin. Blood pressure monitoring is essential for overall health assessment but does not directly relate to the medication's intended effect.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale :
Hypercalcemia - The nurse does not need to monitor for hypercalcemia in this scenario. Hypercalcemia refers to high levels of calcium in the blood, and it is not directly related to the newborn's weight or the mother's diabetes mellitus.
Choice B rationale
Hypobilirubinemia - Hypobilirubinemia is low levels of bilirubin in the blood and is not a major concern for a newborn's weight or the mother's diabetes mellitus. Although jaundice (high bilirubin levels) can be a concern in newborns, it is not the focus in this case.
Choice C rationale
Hypoglycemia - This is the correct choice. Newborns of diabetic mothers are at risk of developing hypoglycemia, which is low blood sugar levels. The baby receives excess glucose from the mother during pregnancy, and after birth, insulin production may be higher than needed, leading to low blood sugar levels. Monitoring for hypoglycemia is crucial to prevent potential complications.
Choice D rationale
Decreased RBC - The nurse does not need to monitor for decreased red blood cells (RBC) specifically related to the newborn's weight or the mother's diabetes mellitus. Monitoring RBC levels is important for other conditions, but it is not the primary concern in this case.
Correct Answer is A
Explanation
Choice A rationale :
Prepare for cesarean birth. The nurse should consider preparing for a cesarean birth as the client is at 39 weeks of gestation and has heavy vaginal bleeding. Heavy vaginal bleeding during pregnancy could indicate an emergency situation such as placental abruption or placenta previa, both of which can be life-threatening for the mother and the baby. In such cases, an emergency cesarean birth might be necessary to ensure the safety of both the client and the baby. Promptly preparing for the procedure will help expedite the process and prevent any delays in providing necessary medical care.
Choice B rationale
Initiate an IV infusion of magnesium sulfate. Magnesium sulfate is not indicated in this situation. Magnesium sulfate is commonly used in obstetrics, particularly in the management of preeclampsia and eclampsia to prevent seizures. However, the client's heavy vaginal bleeding suggests a different issue and magnesium sulfate would not address the underlying cause. Instead, the focus should be on identifying and managing the cause of the bleeding to ensure the best outcome for the client and the baby.
Choice C rationale
Administer antibiotics. Administering antibiotics is not the priority action in this scenario. Heavy vaginal bleeding in a pregnant client requires immediate attention to assess the cause and determine the appropriate course of action. While antibiotics may be necessary in some situations, they are not the first-line treatment for heavy vaginal bleeding during pregnancy. The nurse should focus on providing prompt and appropriate care to address the client's immediate needs.
Choice D rationale
Request the RN to perform a cervical examination. Performing a cervical examination may provide valuable information about the cause of the heavy vaginal bleeding. It can help determine if the bleeding is related to cervical changes, such as cervical dilation or effacement. The findings from the cervical examination, along with other assessments, will aid in making the most appropriate decisions regarding the client's care. However, it is not the only action that the nurse should take. In this critical situation, the nurse must prioritize immediate interventions to ensure the safety and well-being of the client and the baby.
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