Oxytocin
This medication is commonly prescribed to induce or augment labor.
What is oxytocin?
Rationale: Oxytocin stimulates uterine contractions and may be used for labor induction or augmentation.
Betamethasone may be administered when preterm birth is anticipated to promote the development of this fetal organ system.
What are the fetal lungs?
Rationale: Antenatal corticosteroids accelerate fetal lung maturation and reduce complications associated with prematurity.
Terbutaline relaxes this type of muscle, including the uterine muscle.
What is smooth muscle?
Rationale: Terbutaline is a beta-adrenergic agonist that can relax uterine smooth muscle.
This medication is the antidote for magnesium sulfate toxicity.
What is calcium gluconate?
Rationale: Calcium gluconate counteracts the neuromuscular and cardiac effects of excessive magnesium.
These principles include verifying the correct patient, medication, dose, route, time, reason, documentation, education, evaluation, and the client’s right to refuse.
What are the rights of medication administration?
Rationale: Medication rights provide a structured safety check, but they do not replace clinical judgment.
In a client with severe preeclampsia, magnesium sulfate is administered primarily to prevent this complication.
What are seizures?
Rationale: Magnesium sulfate is used for seizure prophylaxis. It is not primarily administered to lower blood pressure.
Oxytocin should be administered through this device so the nurse can control the infusion rate accurately.
What is an electronic infusion pump?
Rationale: Oxytocin is a high-alert medication. An infusion pump allows precise control of the dose and rate.
This is the typical route used to administer betamethasone during pregnancy.
What is the intramuscular route?
Rationale: Betamethasone for fetal lung maturation is administered by deep intramuscular injection.
This maternal vital sign must be assessed carefully before and after administering terbutaline.
What is the maternal heart rate?
Rationale: Terbutaline may cause maternal tachycardia and other cardiovascular effects.
Calcium gluconate should be readily available whenever a client receives this high-alert maternal medication.
What is magnesium sulfate?
Rationale: Rapid access to the antidote is necessary if magnesium toxicity develops.
This communication technique requires the receiving nurse to repeat a verbal or telephone medication order to verify its accuracy.
What is read-back?
Rationale: Read-back helps prevent errors caused by misunderstood verbal communication.
The nurse uses a reflex hammer to monitor this neurological response during magnesium sulfate therapy.
What are deep-tendon reflexes?
Rationale: Diminished or absent deep-tendon reflexes may indicate an excessive magnesium level or magnesium toxicity.
Name four assessments that require continuous or frequent evaluation while a client receives oxytocin for labor induction.
What are the fetal heart rate, contraction frequency, contraction duration, and uterine resting tone?
Acceptable bonus response: Maternal vital signs, pain, cervical change, and intake and output.
Rationale: Oxytocin can produce excessive uterine activity, which may reduce uteroplacental blood flow and compromise the fetus.
This maternal laboratory value may temporarily increase after betamethasone administration.
What is blood glucose?
Rationale: Corticosteroids can cause maternal hyperglycemia. Clients with diabetes may require additional glucose monitoring and adjustment of their treatment plan.
Name three maternal adverse effects associated with terbutaline.
What are tachycardia, palpitations, tremors, nervousness, chest discomfort, hyperglycemia, or shortness of breath?
Rationale: Terbutaline stimulates beta-adrenergic receptors and can cause cardiovascular and metabolic adverse effects.
True or false: Calcium gluconate is routinely administered to every client receiving magnesium sulfate.
What is false?
Rationale: Calcium gluconate is not routinely administered with magnesium sulfate. It is prepared for use when clinically indicated and prescribed, such as suspected magnesium toxicity.
An order reads, “Magnesium sulfate IV—administer per routine.” Explain why the nurse should question the order.
What is an incomplete medication order?
Required explanation: The order does not include a complete dose, concentration, rate, or administration instructions.
Rationale: The nurse should not guess or rely on the phrase “per routine.” The prescription must be clarified before administration.
Name four priority assessments for a client receiving magnesium sulfate.
What are respiratory rate, deep-tendon reflexes, level of consciousness, and urine output?
Additional acceptable responses: Maternal vital signs, fetal heart rate, serum magnesium level, seizure activity, and intake and output.
Rationale: Magnesium depresses the central nervous system and is excreted through the kidneys. Respiratory depression, decreased reflexes, and oliguria increase concern for toxicity.
A client receiving oxytocin has six contractions in 10 minutes. This uterine activity is known by this term.
What is uterine tachysystole?
Rationale: Uterine tachysystole is generally defined as more than five contractions in 10 minutes, averaged over 30 minutes.
True or false: Betamethasone immediately stops preterm contractions.
What is false?
Rationale: Betamethasone promotes fetal maturation. It is not a tocolytic and does not directly stop uterine contractions.
A client experiencing uterine tachysystole may receive terbutaline for this therapeutic purpose.
What is relaxing the uterus and decreasing excessive uterine activity?
Rationale: Terbutaline may be prescribed as an acute intervention for excessive uterine activity.
Name three findings that would cause the nurse to anticipate the possible administration of calcium gluconate.
What are respiratory depression, absent deep-tendon reflexes, significant lethargy or decreased level of consciousness, and other findings of magnesium toxicity?
Additional acceptable response: Cardiac conduction abnormalities associated with severe toxicity.
Rationale: These findings suggest excessive neuromuscular or central nervous system depression from magnesium.
The oxytocin bag is empty. The nurse prepares to connect the new bag to the primary IV line without tracing the tubing from the client to the pump. Identify the safety concern.
What is the risk of connecting oxytocin to the wrong IV line or infusing it at an incorrect rate?
Rationale: The nurse should trace every line from the client to its source and verify the medication, concentration, pump channel, route, and rate according to facility policy.
A client asks, “Will magnesium sulfate lower my blood pressure?” Give the nurse’s best response.
What is, “Magnesium sulfate is primarily used to prevent seizures; you may receive a separate medication to treat severely elevated blood pressure”?
Rationale: Magnesium sulfate is an anticonvulsant in preeclampsia management. Antihypertensive medications are used when blood-pressure treatment is required.
A client receiving oxytocin develops uterine tachysystole with recurrent late decelerations. State the nurse’s priority action and at least three additional interventions.
What is stopping the oxytocin infusion?
Additional interventions:
Rationale: Oxytocin must be stopped when excessive uterine activity is accompanied by a concerning fetal heart rate pattern.
A pregnant client with diabetes is prescribed betamethasone because preterm birth is anticipated. Identify the priority maternal monitoring and the most important teaching.
What are close blood-glucose monitoring and teaching that blood glucose may temporarily increase?
Rationale: Betamethasone can significantly increase glucose levels. The medication may still be beneficial, but the client may need more frequent monitoring and temporary changes to the diabetes-management plan.
After receiving terbutaline, a client develops marked tachycardia, chest pain, and difficulty breathing. State the nurse’s priority actions.
What are holding additional terbutaline, immediately assessing the client, calling for assistance, supporting airway and breathing, and notifying the provider?
Rationale: Chest pain, significant tachycardia, and respiratory difficulty may indicate serious cardiovascular or pulmonary complications and require immediate intervention.
A client has findings of magnesium toxicity. Another nurse says, “Let’s give calcium gluconate first and stop the magnesium afterward.” Correct this plan.
What is stopping the magnesium sulfate infusion immediately, assessing and supporting the client’s airway and breathing, calling for assistance, notifying the provider, and preparing calcium gluconate for administration as prescribed?
Rationale: The source of the toxicity must be stopped immediately. Emergency assessment and respiratory support should not be delayed while the antidote is prepared.
During handoff, the off-going nurse says, “Her magnesium looks fine.” Identify at least five pieces of objective information the receiving nurse should request.
What are the magnesium infusion dose and rate, respiratory rate, oxygenation status as indicated, deep-tendon reflexes, level of consciousness, urine output, maternal vital signs, fetal status, relevant laboratory results, IV-site condition, and time of the most recent assessments?
Rationale: Descriptions such as “looks fine” are subjective. A safe handoff includes specific, measurable clinical information.
A client receiving magnesium sulfate has a respiratory rate of 9/min, absent patellar reflexes, urine output of 20 mL/hr, and increasing lethargy. Identify the suspected complication and place the nursing actions in priority order.
What is magnesium sulfate toxicity?
Priority actions:
Rationale: Respiratory depression, absent reflexes, decreased urine output, and altered consciousness are warning signs of magnesium toxicity.