Exhibits

Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.

A. Blood type: While important for transfusions, blood type is not relevant to assessing pain or determining appropriate pain management strategies. Pain assessment focuses on physiological and behavioral cues, not blood compatibility.
B. Parents’ religious affiliation: Religious beliefs may influence pain management preferences (e.g., preference for non-pharmacologic methods), but this is not a priority assessment before implementing pain management strategies. The immediate focus should be on assessing the infant’s pain level and physiological status.
C. Blood pressure: Pain can cause increased sympathetic nervous system activity, leading to elevated blood pressure. Monitoring blood pressure helps assess the severity of pain and guides appropriate pain management interventions.
D. Level of consciousness: Infants in significant pain may become restless, irritable, or inconsolable, while excessive sedation from pain medications can cause decreased responsiveness. Assessing level of consciousness helps ensure that pain relief measures do not cause over-sedation or respiratory depression.
E. Hearing acuity: Hearing assessment is not relevant for pain management in a 4-month-old infant. Pain assessment in infants focuses on physiological signs, crying, and behavioral responses, rather than auditory abilities.
F. Heart rate: Pain can lead to tachycardia due to sympathetic nervous system activation. Monitoring heart rate helps assess pain intensity and evaluate the effectiveness of pain relief interventions.
G. Deep tendon reflexes: Reflex testing is used for neurological assessment but is not relevant to pain management. Reflexes do not provide direct information about pain intensity or response to treatment.

A. Return of the uterus to prepregnancy size. While oxytocin helps contract the uterus, the complete process of involution (uterus returning to prepregnancy size) takes about 6 weeks postpartum. Oxytocin primarily aids in immediate postpartum contraction to reduce bleeding.
B. Expulsion of the placenta. Oxytocin is typically administered after placental delivery to prevent postpartum hemorrhage. If the placenta does not expel naturally, manual removal may be needed. Oxytocin is more effective in promoting uterine tone rather than actively expelling the placenta.
C. Activation of the let-down reflex. Oxytocin plays a role in milk ejection during breastfeeding, but when administered intravenously postpartum, its primary purpose is to stimulate uterine contractions. Natural oxytocin release from breastfeeding supports the let-down reflex, but this is not the main goal of IV oxytocin administration.
D. Stimulation of uterine contractions. IV oxytocin is given postpartum to promote uterine contractions, which help reduce postpartum bleeding by compressing uterine blood vessels. This action is critical in preventing postpartum hemorrhage and ensuring uterine firmness.