A nurse is caring for a client in the third stage of labor. The healthcare provider orders an IV infusion of Oxytocin. What is the primary purpose of administering oxytocin in this stage?
To prevent infection
To relieve maternal pain after birth
To facilitate rest and relaxation of the uterus
To stimulate uterine contractions to prevent hemorrhage
The Correct Answer is D
A. Oxytocin does not have antimicrobial properties and is not used to prevent infection. Infection prevention during the third stage of labor focuses on aseptic technique and monitoring, not uterotonic medications.
B. Oxytocin is not an analgesic and does not directly relieve maternal pain. Postpartum pain management is addressed with analgesics and nonpharmacologic comfort measures rather than uterine stimulants.
C. Oxytocin causes uterine contraction, not relaxation. Uterine relaxation would increase the risk of postpartum hemorrhage and is the opposite of the desired physiologic effect during the third stage of labor.
D. The primary purpose of administering oxytocin during the third stage of labor is to stimulate strong, coordinated uterine contractions. These contractions promote placental separation and compress uterine blood vessels at the placental site, significantly reducing the risk of postpartum hemorrhage, which is a leading cause of maternal morbidity and mortality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dry skin is a late sign of hypovolemic shock. Early shock often presents with normal skin turgor, and pallor or cool, clammy skin develops as the body compensates.
B. Being alert and oriented is expected in the early stages of hypovolemic shock because mental status changes occur later when perfusion to the brain is compromised.
C. Urinary output below 30 mL/hr is an early indication of hypovolemic shock. The kidneys are highly sensitive to decreased perfusion, and oliguria occurs as the body conserves fluid and maintains blood pressure, making this one of the first measurable signs of shock.
D. Hypotension is a late sign of hypovolemic shock. The body initially compensates with increased heart rate and vasoconstriction to maintain blood pressure, so a drop in blood pressure indicates advanced shock.
Correct Answer is D
Explanation
A. While catheterization may be needed before surgery (e.g., cesarean delivery) to prevent bladder injury and monitor urine output, it is not the first priority in this emergency scenario. The client’s hemodynamic stability must be addressed before preparing for procedures.
B. Preparing for surgery is important, but it is secondary to stabilizing the client. Immediate interventions to address potential hypovolemia take precedence over procedural preparation.
C. Obtaining consent is necessary prior to surgical intervention, but in an urgent situation such as suspected placenta previa with active bleeding, life-saving measures to stabilize maternal circulation take priority over paperwork.
D. This is the priority action. The client is showing signs of hemodynamic instability with hypotension (BP 98/52 mmHg) and tachycardia (HR 118/min), indicating potential hypovolemic shock from hemorrhage, likely due to placenta previa. Establishing large-bore IV access allows for rapid administration of fluid resuscitation, blood products, and medications as needed to maintain maternal perfusion and fetal oxygenation. This intervention directly addresses the most immediate threat to life.
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