NURSING 304 - SAUNDERS ATI PHARMACOLOGY STUDY GUIDE 2020/2021) Complete Solution, A Guide

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The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? 1. Fatigue ... 2. Drowsiness 3. Uterine hyperstimulation 4. Early decelerations of the fetal heart rate Rationale: Often used to induce labor. High doses are often used for uterine hyperstimulation & C/S births. ADVERSE EFFECTS: Hyperstimulation of uterine contractions & non-reassuring fetal HR DISCONTINUE 2. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which finding is noted on assessment? 1. Proteinuria of 3 + 2. Respirations of 10 breaths/ minute 3. Presence of deep tendon reflexes 4. Serum magnesium level of 6 mEq/ L Rationale: Mg TOXICITY RESP. DEPRESSION, LOSS OF TENDON REFLEXES & SUDDEN DECLINE IN FETAL HR, MATERNAL HR, & BP caused by Mg tx. Must remain within therapeutic serum levels 4–7.5 mEq/L. Proteinuria 3+ is expected in a pt w/ preeclampsia. 3. The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes Rationale: Mg sulfate is a CNS depressant that relaxes smooth muscles like the uterus. It’s used to STOP preterm labor contractions and for preeclampsia pts. to PREVENT SEIZURES. ADVERSE EFFECTS:  Flushing  Depressed respirations  Depressed deep tendon reflexes  Hypotension  Extreme muscle weakness  Decreased urine output  Pulmonary Edema  Elevated Mg serum levels 4. The nurse instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. “I will flush the eyes after instilling the ointment?” 2. “I will clean the newborn’s eyes before instilling ointment.” 3. “I need to administer the eye ointment within 1 hr. after delivery.” 4. “I will instill the eye ointment into each of the NB’s conjunctiva sacs.” Rationale: Eye prophylaxis protects the NB against Neisseria gonorrhea & Chlamydia trachomatis. The eyes are NOT FLUSHED AFTER INSTILLATION of med because the flush would WASH AWAY the administered medication. [Show More]

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