A nurse is monitoring a laboring person who is receiving oxytocin for labor induction. What is the priority assessment during oxytocin infusion?

Correct Answer: C

Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.

Correct Answer: A

Rationale: The correct answer is A: Swelling and redness of the calf. Postpartum women are at a higher risk for DVT due to hormonal changes and immobility. Swelling and redness in the calf indicate possible DVT as blood clots can cause inflammation and blockage in the veins. Pain in the lower leg (B) is a common symptom but not the most specific for DVT. Heat intolerance (C) and cold intolerance (D) are not typically associated with DVT and are unrelated symptoms in this context.

Correct Answer: D

Rationale: The correct answer is D: to control excessive vaginal bleeding. Episiotomy is primarily performed to manage and control postpartum hemorrhage by facilitating better visualization and access for suturing any bleeding vessels. It is not routinely done for preventing severe tears, expediting birth, or addressing shoulder dystocia, as there are alternative interventions for these situations. Episiotomy should be carefully considered and performed only when necessary to avoid unnecessary complications and promote better outcomes.

Correct Answer: C

Rationale: Rationale: C is correct because assessing for uterine atony is crucial before administering a postpartum tetanus shot to ensure no postpartum hemorrhage risk. Uterine atony can lead to excessive bleeding, which can be exacerbated by the tetanus shot. Summary: A - Verifying immunization status is important but not the most immediate action. B - Assessing blood pressure is important but not directly related to the risk of postpartum hemorrhage. D - Preparing for a cesarean section is not necessary for administering a postpartum tetanus shot.

Correct Answer: A

Rationale: The correct answer is A: perform uterine massage. This is the priority intervention for a boggy uterus to prevent postpartum hemorrhage by promoting uterine contraction and reducing bleeding. Uterine massage helps the uterus to firm up and expel clots. Early ambulation (B) and positioning (C) can support recovery but do not directly address the boggy uterus. Performing a pelvic exam (D) is not necessary for managing a boggy uterus and may even exacerbate bleeding.