A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following finding should the nurse expect?
Explanation & Rationale
Rationale: A. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy uterus located above the umbilicus suggests uterine atony, which indicates that the oxytocin may not have been effective. This finding is not expected 30 minutes after administering oxytocin. B. Client report of burning with urination: Burning during urination is unrelated to oxytocin administration and may point toward a urinary tract infection. It does not reflect the expected physiological response to uterine stimulation for controlling postpartum hemorrhage. C. Saturation of perineal pad in 15 min: Continued excessive bleeding despite oxytocin administration indicates treatment failure and requires immediate intervention. Oxytocin should reduce uterine bleeding; thus, ongoing hemorrhage is not an expected finding. D. Client report of uterine cramping: Uterine cramping is an expected response to oxytocin, which works by stimulating uterine smooth muscle contractions. These cramps help compress blood vessels at the placental site, reducing postpartum bleeding and promoting involution.