A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
Methylergonovine 0.2 mg IM now.
Insert an indwelling urinary catheter.
Obtain laboratory study of prothrombin and partial thromboplastin time.
Administer oxygen by nonrebreather mask at 5 L/min.
The Correct Answer is A
Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.
Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.
Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.
Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason:
Limiting alcohol consumption is important during pregnancy to prevent fetal alcohol syndrome and other developmental issues, but it is not specifically related to the prevention of neural tube defects. Alcohol can interfere with the body's ability to absorb certain nutrients, but folic acid intake is the key factor in preventing neural tube defects.
Choice b reason:
Avoiding foods containing aspartame is often recommended for overall health, but there is no direct link between aspartame and neural tube defects. Aspartame is an artificial sweetener found in many diet foods and beverages, and while some people choose to avoid it for various health reasons, it is not specifically associated with neural tube defects.
Choice c reason:
Increasing the intake of iron-rich foods is crucial for preventing anemia during pregnancy and ensuring the baby has enough iron stores. However, iron does not play a direct role in the prevention of neural tube defects. Neural tube defects are related to folic acid, not iron.
Choice d reason:
Consuming foods fortified with folic acid is the most critical factor in preventing neural tube defects. Folic acid is a B vitamin that is essential for the proper development of the neural tube, which becomes the baby's brain and spinal cord. Adequate folic acid intake before conception and during early pregnancy can significantly reduce the risk of neural tube defects.
Correct Answer is B
Explanation
The correct answer is choice B. At the level of the umbilicus.
Choice A rationale:
The fundus is typically not found 2 cm above the umbilicus 12 hours postpartum. This position is more common immediately after delivery or in cases of uterine atony or retained placental fragments.
Choice B rationale:
At 12 hours postpartum, the uterine fundus is expected to be at the level of the umbilicus. This indicates normal involution of the uterus, where it contracts and shrinks back to its pre-pregnancy size.
Choice C rationale:
One fingerbreadth above the symphysis pubis is not a typical position for the fundus 12 hours after delivery. This position is more likely several days postpartum as the uterus continues to involute.
Choice D rationale:
The fundus being to the right of the umbilicus may indicate a full bladder, which can push the uterus to one side. This is not a normal finding 12 hours postpartum and would require intervention to empty the bladder.
: https://bchsfoutreach.ucsf.edu/sites/bchsfoutreach.ucsf.edu/files/handouts/Washington%20Hospital%20Postpartum%204-2018.pdf : https://nursekey.com/fundal-palpation-postpartum/
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.