A 36-year-old patient who is gravida 5 para 5 (G5P5) was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.
She was in labor for 25 hours and forceps were used to assist with the delivery.
She was given an epidural for anesthesia that was effective.
The labor and delivery nurse reported that the patient had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.
Her vital signs were stable.
Based on the assessment data, the nurse recognizes the need to intervene immediately.
Select the 5 priority interventions that the nurse should initiate based on the recent assessment.
Administer 0.2 mg methylergonovine IM
Notify primary healthcare provider
Insert straight catheter
Massage fundus until firm
Count saturated pads per hour
Administer 2 units of packed red blood cells (PRBC)
Increase the IV fluid to maximum rate
Weigh all bloody materials .
Correct Answer : A,B,C,D,E
Choice A rationale
Methylergonovine is used after childbirth to help control bleeding and improve muscle tone in the uterus. Administering 0.2 mg of methylergonovine IM can help to control postpartum hemorrhage in this patient.
Choice B rationale
Notifying the primary healthcare provider is crucial in this situation. The healthcare provider needs to be aware of the patient’s condition and the interventions being initiated.
Choice C rationale
Inserting a straight catheter can help to manage urinary retention, which could be a potential issue given the patient’s prolonged labor and use of epidural anesthesia.
Choice D rationale
Massaging the fundus until it is firm can help to stimulate uterine contractions, which can control bleeding and prevent postpartum hemorrhage.
Choice E rationale
Counting saturated pads per hour can help to monitor the amount of bleeding and assess the effectiveness of the interventions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","H"]
Explanation
H.
Choice A rationale
While albuterol can cause an increase in heart rate due to its beta-agonist effects, it is not the primary assessment following administration. The main goal of albuterol treatment is to improve respiratory function.
Choice B rationale
Breath sounds are a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve breath sounds by reducing bronchospasm and increasing airflow.
Choice C rationale
Serum sodium levels are not directly affected by albuterol and therefore are not a primary assessment following its administration.
Choice D rationale
A complete blood count is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice E rationale
Oxygen saturation is a primary assessment following albuterol administration. Albuterol should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice F rationale
Peak inspiratory flow is not typically assessed after albuterol administration. Albuterol primarily affects expiratory flow by reducing bronchospasm.
Choice G rationale
Temperature is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice H rationale
Peak expiratory flow is a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve peak expiratory flow by reducing bronchospasm.
Correct Answer is C
Explanation
Choice C rationale
In a hurricane disaster medical area, drinking water contaminated by sewage is a common source of contamination that could lead to diarrhea. Hurricanes and severe storms often result in flooding, which can contaminate drinking water supplies with sewage and other pollutants. This can lead to the spread of waterborne diseases, including those that cause diarrhea. Type 2 diabetes Explore
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