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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale :

The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.

Choice B rationale

Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.

Choice C rationale

Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.

Choice D rationale

Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.

A. 7 B. 8 C. 9 D. 10.

Correct Answer is A

Explanation

Step 1 is assessing heart rate. A heart rate of 130/min earns 2 points since a rate above 100/min is optimal.

Step 2 is assessing respiratory effort. A lusty cry earns 2 points as strong crying indicates good respiratory function.

Step 3 is assessing muscle tone. Flexed extremities earn 1 point since full active movement would score 2.

Step 4 is assessing reflex irritability. Grimace when suctioned earns 1 point as a vigorous response (cough, sneeze) would score 2.

Step 5 is assessing color. Acrocyanosis earns 1 point since a fully pink body scores 2.

Final answer: 7

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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?

Nursing Test Bank

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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