The nurse is reviewing the labor and delivery plan for a pregnant client who is scheduled to receive oxytocin (Pitocin) for induction of labor contractions. Which client statement indicates the need for additional instruction from the nurse?
1. "I want to walk around as much as possible to help stimulate my labor."
2. "I will receive gradually increasing doses of the medication until I'm in active labor."
3. "I realize my blood pressure will need to be taken frequently as long as I am on this medication."
4. "I will tell you if I develop a headache."
Correct Answer: 1
Rationale 1: Clients receiving oxytocin require continuous fetal and maternal monitoring, so the client needs to realize that walking around will not be possible.
Rationale 2: Doses of intravenous oxytocin are increased gradually, every 15 to 60 minutes, until a normal labor pattern is established.
Rationale 3: Vital signs, including blood pressure, should be checked at least every 15 minutes.
Rationale 4: A headache could be a sign of increased blood pressure, which might lead to a need to discontinue the oxytocin.
Global Rationale: Clients receiving oxytocin require continuous fetal and maternal monitoring, so the client needs to realize that walking around will not be possible. Doses of intravenous oxytocin are increased gradually, every 15 to 60 minutes, until a normal labor pattern is established. Vital signs, including blood pressure, should be checked at least every 15 minutes. A headache could be a sign of increased blood pressure, which might lead to a need to discontinue the oxytocin.
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