The client is receiving oxytocin (Pitocin) for induction of labor. Which assessment finding will most likely result in the nurse stopping the infusion?
1. The client tells the nurse she has a serious headache.
2. The vaginal exam reveals that the client is entering transition.
3. The client reports that the uterine contractions are strong in intensity.
4. Uterine contractions occur every 2 to 3 minutes and last 40 to 60 seconds.
Correct Answer: 1
Rationale 1: The headache could indicate hyponatremia (water intoxication) due to the effects of oxytocin (Pitocin); the client should be assessed for fluid balance.
Rationale 2: The infusion should not be stopped when the client enters transition.
Rationale 3: Contractions that are strong in intensity are no reason to stop the infusion.
Rationale 4: Uterine contractions every 2 to 3 minutes and lasting 40 to 60 seconds are expected with induction of labor.
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