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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason:

Maternal exhaustion is a maternal indication for the use of vacuum extraction. Vacuum extraction is a technique that can assist the mother in delivering the baby when she is unable to push effectively or when pushing poses a risk to her health. Vacuum extraction can shorten the second stage of labor and reduce maternal fatigue and distress. According to the Cleveland Clinic, vacuum extraction might be indicated if "the mother can't push anymore, either due to exhaustion or a health condition.".

Choice B reason:

Failure to progress past 0 station is not a maternal indication for the use of vacuum extraction. The station refers to the position of the baby's head in relation to the mother's pelvis. 0 station means that the baby's head is at the level of the pelvic inlet, or the narrowest part of the pelvis. Vacuum extraction is usually not performed before the baby reaches +2 station, which means that the head is 2 cm below the pelvic inlet and visible at the vaginal opening. According to the American Academy of Family Physicians, vacuum extraction should not be attempted if "the fetal head is not engaged (above 0 station).".

Choice C reason:

A wide pelvic outlet is not a maternal indication for the use of vacuum extraction. The pelvic outlet is the lower part of the pelvis that forms the exit for the baby during delivery. A wide pelvic outlet means that there is more space for the baby to pass through, which can facilitate vaginal delivery and reduce the need for instrumental assistance. Vacuum extraction is more likely to be indicated when there is a narrow pelvic outlet, which can obstruct labor and cause fetal distress.

Choice D reason:

A history of rapid deliveries is not a maternal indication for the use of vacuum extraction. Rapid deliveries, also known as precipitous deliveries, are those that occur within 3 hours of the onset of labor. Rapid deliveries can pose risks to both the mother and the baby, such as excessive bleeding, umbilical cord prolapse, or birth trauma. However, vacuum extraction is not usually indicated in these cases, as it requires time and preparation to apply the device and monitor its effects. Vacuum extraction is more likely to be indicated when labor is prolonged or stalled in the second stage, and when there is a nonreassuring fetal heart rate.

A. Rupture of the membranes. B. Pattern of contractions. C. Changes in the cervix. D. Station of the presenting part.

Correct Answer is C

Explanation

Choice A reason:

Rupture of the membranes is not a reliable sign of true labor, as it can occur before or during labor, or be artificially induced by the provider. • Choice B reason:

Patterns of contractions can vary depending on the stage and phase of labor, and can also be influenced by factors such as hydration, activity, and medication. Contractions alone do not indicate true labor unless they are accompanied by cervical changes. • Choice C reason:

Changes in the cervix, such as effacement (thinning) and dilation (opening), are the most accurate indication of true labor. Cervical changes are caused by the pressure of the presenting part and the force of the contractions. The nurse should assess the cervix periodically to determine the progress of labor. • Choice D reason:

The station of the presenting part refers to the relationship of the fetal head to the maternal ischial spines, which are bony landmarks in the pelvis. The station can range from -5 (high) to +5 (low), with 0 being at the level of the ischial spines. Station does not indicate true labor, as it can vary depending on the parity, pelvic shape, and fetal position of the client.

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The priority nursing care associated with an oxytocin (Pitocin) infusion is:

Nursing Test Bank

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A maternal indication for the use of vacuum extraction is

Correct Answer is A

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is C

Explanation

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