When caring for a client receiving IV oxytocin infusion, the nurse observes the client has developed a pounding pulse, increased blood pressure, and moist respirations. The nurse prepares to:
a. increase the oxytocin infusion rate. c. lower the head of the client's bed.
b. discontinue the client's IV access. d. decrease the oxytocin infusion rate.
ANS: D
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A Incorrect: This would make the client's condition worse, creating an environment for hypertensive crisis, fetal arrhythmia, or death.
B Incorrect: Even if the IV infusion is discontinued, the IV access must be maintained for potential emergency care.
C Incorrect: This will worsen both the hypertension and the difficulty breathing.
D Correct: These are manifestations of water intoxication or circulatory overload, requiring the rate of IV oxytocin to be decreased.
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