After an hour of oxytocin therapy, a patient in labor experiences headache and vomiting. What should the nurse do?
A) Assess the vagina for full dilation.
B) Notify the physician and stop the infusion.
C) Instruct the patient to breathe in and out rapidly.
D) Administer oral orange juice for added potassium.
B
Feedback:
A side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water intoxication. This is first manifested by headache and vomiting. If these danger signs are observed in the patient during induction of labor, report them immediately and halt the infusion. Assessing the vagina for dilation, increasing respirations, and administering orange juice for potassium will not help with water intoxication.
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