Practice Questions Part 2

A nurse is preparing to administer morphine oral solution 0.04mg/kg to a newborn who weighs 2.5kg. The amount available is morphine oral solution 0.4mg/mL. How many mL should the nurse administer?

0.25 mL

A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue you IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."

B. "The bleeding is minimal until I discontinue you IV medication." The flow of lochia is often scant while receiving oxytocin medication until the effects of the medication wear off. This can be observed regardless of the administration route of the oxytocic medication.

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. Tachycardia B. Hypoglycemia C. Flushed skin D. Generalized petechiae

B. Hypoglycemia Newborn hypothermia can cause hypoglycemia because anaerobic glycolysis can deplete glycogen stores

A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/min

C. Mottling The nurse should report mottling to the provider as an indication of hypothermia or respiratory distress

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? A. Diarrhea B. Thromboembolism C. Fetal asphyxia D. Oliguria

C. Fetal asphyxia Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns.

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

C. Prolapsed umbilical cord The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately.

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn

A, B, D Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. A distended bladder displaces the uterus and can prevent adequate contraction of the uterus. Also, prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting.

A nurse is caring for a client who is at 16 weeks gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? A. Use a 20-gauge needle and administer the medication using the Z-track method B. Use a 22-gauge needle and administer the medication deep into the thigh C. Use a 25-gauge needle and administer the medication into the deltoid muscle D. Use an 18 gauge needle and administer the medication into the rectus femoris muscle.

A. Use a 20-gauge needle and administer the medication using the Z-track method The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20-gauge needle is the correct size.

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common for expectant fathers in early pregnancy." C. "I'm sure that accepting this situation is challenging when it's your baby, too." D. "You should speak to a therapist about these feelings."

B. "These feelings are common for expectant fathers in early pregnancy." The father needs reassurance that these feelings are expected. the nurse should reassure him that when the pregnancy becomes obvious, he will feel more involved. This therapeutic response addresses the client's feelings by providing information.

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? A. Check for a full bladder B. Massage the fundus C. Measure vital signs D. Administer carboprost IM

B. Massage the fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The primary cause of early postpartum bleeding is uterine atony, which is manifested by a relaxed, boggy uterus. Thus, the greatest risk for this client is hemorrhage. The nurse should massage the client's fundus first. The nurse should use Maslow's hierarchy of needs, the ABCs priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelactasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enerocolitis

B. Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. Is is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathy of prematurity, the vessels grow abnormally form the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness.

A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take? A. Ensure the client has a full bladder B. Stand at the client's right side if the nurse is right-handed C. Assist the client onto her back with knees extended D. Palpate the outline of the fetus's head with the palms of the hands

B. Stand at the client's right side if the nurse is right-handed The nurse should stand facing the client on the side that correlates with the nurse's dominant hand; therefore, if the nurse is right-handed, the nurse should stand on the client's right side

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord B. They can cause delayed cord separation. C. They can cause swelling of the surrounding tissue D. They can cause skin discoloration

B. They can cause delayed cord separation. There is no evidence that antimicrobial preparations are of any benefit in the process of the drying and detachment of the umbilical cord stump. Keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection.

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30 degree angle D. Place the client in a semi-Fowler's position

C. Elevate the client's legs to a 30 degree angle The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30 degree angle. This improves blood flow and reduces manifestations of hypotension.

A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O negative. Which of the following actions should the nurse take? A. Administer a dose of Rhogam B. Request a prescription for an antibiotic until delivery C. Instruct the client to obtain a rubella immunization after delivery D. Inform the client that she will need to deliver via cesarean birth

C. Instruct the client to obtain a rubella immunization after delivery This client is not immune to rubella and should receive this immunization after delivery.

A nurse is caring for a client in the latent stage of labor who is reporting a pain level on 4 on a scale of 1-10. Which of the following actions should the nurse take? A. Encourage the client to use hydrotherapy B. Teach the client biofeedback to control labor pain C. Lead the client in relaxation breathing techniques D. Administer a benzodiazepine medication

C. Lead the client in relaxation breathing techniques Relaxation breathing techniques in the first stage of labor promote relaxation of the abdominal muscles. This decreases discomfort and allows fetal descent.

A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools

C. Nasal flaring Nasal flaring, grunting, and respiratory muscular retractions signal serious breathing problems that should be reported to the provider

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? A. Breast engorgement B. Hypothermia C. Urinary retention D. Rupture of membranes

C. Urinary retention After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a large bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors.

A nurse is teaching a female client about nutrition during pregnancy. Which of the following instructions should the nurse include in the teaching? A. "Plan to double your normal caloric intake during the last trimester of pregnancy." B. "Expect to gain 10-15 lb during pregnancy." C. "Restrict your intake of sodium throughout pregnancy." D. "Do not eat swordfish, shark, or king mackerel while you are pregnant."

D. "Do not eat swordfish, shark, or king mackerel while you are pregnant." These fish have high levels of mercury, which can harm the developing nervous system of the fetus. Consumption should be avoided prior to conception and until the cessation of breastfeeding.

A nurse is providing teaching for a client at 7 weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates to the nurse an understanding of the teaching? A. "I should eat fatty foods to increase my caloric intake." B. "I should brush my teeth right after eating." C. "Acupressure bands on my elbows might help me feel better." D. "I should have a small snack before bedtime."

D. "I should have a small snack before bedtime." A small snack at bedtime can relieve nausea and vomiting through the night and prevent the client from feeling too hungry on waking.

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."

D. "I will avoid any of my family members who are ill." The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis.

A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? A. "My ankles are swollen at the end of the day." B. "I can feel my baby kicking my ribs, and it is very uncomfortable." C. "I'm growing more and more worried every day." D. "My heart feels like it is racing."

D. "My heart feels like it is racing." The nurse should apply the urgent vs nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority need because they pose more of a threat to the client. The nurse should assess the client's heart rate. The primary action of terbutaline involves bronchodilation and relaxation of smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified. The nurse might also need to use Maslow's hierarchy if needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain Which of the following actions should the nurse take? A. Instruct the client to pant during contractions B. Position the client supine with legs elevated C. Encourage the client to soak in a warm bath D. Apply pressure to the client's sacral area during contractions

D. Apply pressure to the client's sacral area during contractions The nurse should provide counter-pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counter-pressure lifts the fetal head away from the sacral nerves, which decreases pain.

A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy? A. Quickening B. Breast tenderness C. Uterine enlargement D. Auscultation of a fetal heart rate

D. Auscultation of a fetal heart rate the auscultation of a fetal heart rate is a conclusive sign of pregnancy

A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take? A. Discontinue oxytocin infusion B.. Prepare for emergency cesarean delivery C. Position the parent to facilitate the McRoberts maneuver D. Gather equipment for neonatal resuscitation

D. Gather equipment for neonatal resuscitation meconium-stained amniotic fluid can cause neonatal meconium aspiration syndrome. The nurse should gather equipment for neonatal resuscitation.

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea

D. Gonorrhea Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC

A nurse is assisting with monitoring the fetal heart rate tracings of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Baseline fetal heart rate of 110-130/min B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia

D. Late decelerations with fetal bradycardia The nurse should identify that a fetal monitor showing recurrent late decelerations and bradycardia indicates that the fetus is not tolerating labor and may be compromised. These findings should be assessed in relation to the clinical picture of the progression of labor. The nurse should notify the provider to update the plan of care for the client and her baby.

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine

D. Methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions

A nurse is planning care for a client who is pregnant and has a deep-vein thrombosis (DVT). Which of the following actions should the nurse include? A. Apply compression stockings each morning after assisting the client to the bathroom B. Gently massage the affect extremity for 10 minutes twice daily C. Apply cold compresses to the affected extremity for 20 minutes 4 times per day D. Monitor the client for bleeding form intravenous insertion sites

D. Monitor the client for bleeding form intravenous insertion sites The nurse should monitor the client for bleeding from IV or venipuncture sites, hematuria, and increased vaginal bleeding. The treatment for DVT includes anticoagulant therapy, which increases the client's risk of bleeding and postpartum hemorrhage.

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Don sterile gloves prior to puncturing the newborn's heel B. Puncture the center aspect of the newborn's heel C. Elevate the newborn's heel prior to the procedure D. Warm the heel with a warm washcloth prior to the procedure

D. Warm the heel with a warm washcloth prior to the procedure The nurse should warm the heel with a warm washcloth for 5-10 minutes prior to the procedure to enhance blood flow to the heel.

A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? A. Contractions that last for 60 sec each with a 4 min rest between contractions B. Contractions that last for 60 sec each with a 3 min rest between contractions. C. A contraction the lasts for 4 min followed by a period of relaxation D. Contractions that last for 45 sec each with a 3 min rest between contractions

B. Contractions that last for 60 sec each with a 3 min rest between contractions. A contraction interval indicates how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 minutes is equivalent to contractions every 4 minutes

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1-2hr of delivery? A. Naloxone B. Erythromycin ophthalmic ointment C. Poractant alfa D. Rotavirus immunization

B. Erythromycin ophthalmic ointment Every newborn born in the US should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth

A nurse is caring for a client who delivered a stillborn child. Which of the following actions should the nurse take? A. Tell the parents that they should hold their child while they have the chance B. Stay with the parents as long as the child is still in the mother's room C. Discourage the parents from viewing any of the child's congenital anomalies D. Allow the parents to keep the child in their room for as long as they wish

D. Allow the parents to keep the child in their room for as long as they wish The parents should have unrestricted access to the child's body. This time allows them to process the traumatic event. Evidence shows that the risk of infection caused by having a deceased body in the room is minimal. Most parents will be ready to say goodbye to the body when it begins to show obvious signs of deterioration.

A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first? A. Place the client in an extreme Trendelendburg position B. Increase the IV fluid infusion rate C. Manually apply upward pressure intravaginally on the presenting part D. Administer 8-10L/min of oxygen via a nonrebreather face mask

C. Manually apply upward pressure intravaginally on the presenting part The greatest risk to this client is fetal CNS injury or death from fetal hypoxia due to cord compression. Therefore, the first action the nurse should take is to insert a gloved hand into the vagina and apply upward pressure to the presenting part to move it away from the cord.

A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent neural tube defects? A. Take a multivitamin every day B. Decrease consumption of mercury-containing fish C. Increase consumption of dairy products D. Begin taking a folic acid supplement

D. Begin taking a folic acid supplement Adequate amounts of folic acid are necessary for fetal neural tube development. All women of child-bearing age and intention should take a folic acid supplement of 0.4mg.

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy

A. Hyperbilirubinemia The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus.

A nurse is providing nutritional counseling for a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet? A. Iron B. Calcium C. Vitamin E D. Vitamin K

A. Iron Iron supplements are recommended during pregnancy to promote adequate transfer of iron to the fetus and to support the expansion of the maternal RBC mass.

A nurse is providing teaching about weight gain during pregnancy for a client who is a primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include? A. "You should plan to gain 25-35 pounds during your pregnancy." B. "You should plan to gain 11-20 pounds during your pregnancy." C. "Because you started pregnancy at a normal BMI and weight, your weight gain is not limited as long as you follow a healthy, balanced diet." D. "Because you are of normal weight prior to pregnancy, you are encouraged to gain 28-40 pounds during pregnancy."

A. "You should plan to gain 25-35 pounds during your pregnancy." A client of normal pre-pregnancy weight should plan to gain 11.3-15.9kg (25-35lb) during pregnancy. Weight gain is primarily for maternal tissue growth during the first and second trimesters and fetal tissue growth during the third trimester.

A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect? A. Symmetric rib cage B. Dry, wrinkled skin C. Vernix over the entire body D. Abundant lanugo on the back

A. Symmetric rib cage A newborn who was born at 39 weeks gestation is full-term and should have a symmetric rib cage

A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should notify the provider about which of the following assessment findings? A. The client reports a frequent cough B. The client reports that none of her shoes fit anymore C. The client reports a weight gain of 2lb in a 2-week period D. The client reports leg cramps in the evening

A. The client reports a frequent cough A frequent cough could be an indication of cardiac decompensation and should be reported to the provider

A postpartum nurse is caring for a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect? A. Urinary output of 40 mL/hr B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hangs with prompt capillary refill

C. Weak and irregular pulse A weak, irregular, and rapid pulse can indicate postpartum hemorrhagic shock due to decreased oxygenation and perfusion to the heart. The client will need fluid replacement and medical attention.

A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority? A. Blood pressure 90/52 mmHg B. Ketones 2+ C. Specific gravity 1.035 D. Sodium 130 mEq/L

B. Ketones 2+ The greatest risk to this client is malnutrition that poses a serious risk to the developing fetus. Ketonuria indicates that the client's body is breaking down fat and protein stores for energy and cannot provide the fetus with essential nutrients. Therefore, this is the priority finding, and the nurse should report it to the provider immediately.

A nurse is caring for a client who has oliohydramnios. Which of the following anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

B. Renal agenesis Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligiohydramnios.

A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski

C. Tonic neck To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when the newborn is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned the head while the opposite arm and leg flex. This reflex persists for about 3-4 months

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."

C. "I may notice increased cramping when I am feeding my baby." The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contractions.

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. "Clean the lesions twice a day with hydrogen peroxide." B. "Apply a hot compress to the affected areas." C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." D. "Expect to receive penicillin prior to delivery."

C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." Acyclovir is an antiviral medication that helps reduce the manifestations of a genital herpes simplex infection. However, topical acyclovir is a pregnancy risk category C medication, so the provider and the client should weigh the risks and benefits of this therapy.

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving the vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

C. Baker's yeast An allergy to baker's yeast is a contraindication to receiving the hepatitis B vaccine. the nurse should notify the client's provider

A nurse is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? A. Urinary output B. Blood pressure C. Fundal consistency D. Pulse rate

C. Fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.