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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 .

Answer and Explanation

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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

I should have taken some allergy medications before going on the hike.- Understanding: Allergens can trigger asthma symptoms, and taking allergy medication can help prevent an asthma attack.
I have been very stressed out lately and should work on stress management.- Understanding: Stress can exacerbate asthma symptoms. Managing stress effectively can help control asthma.
I should have taken an extra dose of fluticasone-salmeterol.- No Understanding: Medication dosage should be as prescribed by the healthcare provider. Taking an extra dose without medical advice can lead to side effects and is not necessarily effective in preventing an asthma attack.
I should have eaten a snack halfway through the hike.- No Understanding: While maintaining good nutrition is important for overall health, eating a snack specifically during a hike is not directly related to preventing an asthma attack.
My friend smoked cigarettes during the hike.- Understanding: Secondhand smoke is a common trigger for asthma. Avoiding exposure to cigarette smoke can help prevent asthma symptoms.

A. Thick, dry, and dark area on bilateral heels. B. Broken skin without evidence of undermining. C. Defined area of persistent redness over bone. D. Superficial sacral pressure injury with defined margins.

Correct Answer is C

Explanation

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

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Naxlex Comprehensive Predictor Exams

Exhibits For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

The nurse observes that a client with ascites is dyspneic.Which action should the nurse implement first?

An older adult client informs the nurse of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). What action should the nurse take?

The patient is resting in bed and cooperative with her mother at her bedside. Which of the following assessments were made?

A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea.Which source of contamination should the nurse consider when interviewing the client about exposure?