65. A client, who is gravida 2, para 1, is at 42 weeks' gestation with gestational diabetes that is controlled with diet. A physician orders an intravenous infusion of oxytocin for the induction of labor due to postdates pregnancy. When caring for the client who is receiving intravenous oxytocin, the nurse should monitor for:
Test-Taking Tip
Look for an assessment specific to the side effects of oxytocin induction, not general assessments or assessment of a condition that the client does not have. The effect on the fetus (Answer 4) is most significant for the nurse to monitor.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Interactions
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Answer 1 is incorrect because maternal hypoglycemia is unrelated to the administration of oxytocin, either for induction of labor or for use after delivery. Answer 2 is incorrect because fetal movement is a general assessment for all clients in labor; it is not specific to the administration of oxytocin. Answer 3 is incorrect because maternal hyperreflexia is an assessment specifically for a client with preeclampsia, not Pitocin induction. Answer 4 is correct because oxytocin administration can be associated with tetanic contractions and inadequate resting period between contractions, resulting in fetal bradycardia.
