A client has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus. The client now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to:

Question

Quizplus · Accepted Answer

Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent client history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the client's complaints of difficulty breathing suggest that the client is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the client can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the client, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time.

A Client Has Been Treated with Oxytocin (Pitocin) for Postpartum