The priority nursing care associated with an oxytocin (Pitocin) infusion is:
Measuring urinary output.
Evaluating cervical dilation.
Increasing infusion rate every 30 minutes.
Monitoring uterine response.
The Correct Answer is D
Choice A reason:
Measuring urinary output. This is not the priority nursing care associated with an oxytocin infusion, because urinary output is not directly affected by oxytocin. Urinary output may be affected by other factors, such as fluid intake, dehydration, or kidney function, but these are not related to oxytocin administration. • Choice B reason:
Evaluating cervical dilation. This is also not the priority nursing care associated with an oxytocin infusion, because cervical dilation is a result of uterine contractions, not oxytocin itself. Oxytocin is used to stimulate or augment uterine contractions, but it does not cause cervical dilation directly. Cervical dilation is important to monitor during labor, but it is not the main focus of oxytocin infusion. • Choice C reason:
Increasing infusion rate every 30 minutes. This is not the priority nursing care associated with an oxytocin infusion, because increasing the infusion rate every 30 minutes is not a standard protocol for oxytocin administration. The infusion rate should be adjusted according to the patient's response and the provider's orders, but not arbitrarily or routinely. Increasing the infusion rate too quickly or too often can cause hyperstimulation of the uterus, which can be dangerous for both the mother and the fetus.
• Choice D reason:
Monitoring uterine response. This is the correct answer and the priority nursing care associated with an oxytocin infusion, because oxytocin can cause excessive or prolonged uterine contractions, which can lead to fetal distress, uterine rupture, or placental abruption. Therefore, the nurse must monitor the frequency, duration, and intensity of uterine contractions, as well as the fetal heart rate and blood pressure, to ensure that oxytocin is having the desired effect and not causing any adverse outcomes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Change her position to the right side
Changing the mother’s position to the right side can sometimes help improve fetal oxygenation by relieving pressure on the vena cava. However, since the mother is already lying on her left side, which is typically the preferred position to optimize blood flow, changing to the right side may not be as effective .
Choice B: Place a wedge under the left hip
Placing a wedge under the left hip is a common intervention to improve uteroplacental blood flow. This position helps to tilt the uterus off the vena cava, enhancing venous return and improving cardiac output, which can positively affect fetal oxygenation. This is why it is the correct answer.
Choice C: Lower the head of the bed
Lowering the head of the bed can help increase blood flow to the upper body and brain, but it does not specifically address the issue of improving uteroplacental blood flow. This action is less targeted for resolving nonreassuring fetal heart rate patterns.
Choice D: Place the mother in a Trendelenburg position
The Trendelenburg position, where the mother is laid flat on her back with her feet elevated higher than her head, is generally used to treat hypotension or to improve venous return in cases of shock. However, it is not typically recommended for nonreassuring fetal heart rate patterns as it can increase pressure on the diaphragm and reduce respiratory efficiency.
Correct Answer is A
Explanation
Choice A reason:
Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.
Choice B reason:
Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.
Choice C reason:
Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.
Choice D reason:
Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.
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