A nurse is caring for a client who is in the third stage of labor and has a prescription for IV oxytocin administration following expulsion of the placenta.
Which of the following clinical manifestations should the nurse expect as a therapeutic effect of the medication?
The client reports a feeling of vaginal fullness.
The client's fundus is firm and midline.
The client saturates a perineal pad in 1 hr.
The client's umbilical cord lengthens.
The Correct Answer is B
Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
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Color: Consistent with genetic background
- Interpretation: B) Sign of potential improvement
- Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.
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Axillary Temperature: 36.3°C (97.4°F)
- Interpretation: B) Sign of potential improvement
- Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.
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Reflex Irritability: Cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.
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Muscle Tone: Flaccid
- Interpretation: C) Sign of potential worsening condition
- Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.
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Respiration Effort: Good cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.
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Heart Rate: 140/min
- Interpretation: B) Sign of potential improvement
- Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.
Correct Answer is A
Explanation
Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.
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