A nurse is admitting a client who experienced a vaginal birth 2 hr 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?

Insert an indwelling urinary catheter.

Administer oxygen by nonrebreather mask at 5 L/min.

Methylergonovine 0.2 mg IM now.

Obtain laboratory study of prothrombin and partial thromboplastin time.

Answer and Explanation

The Correct Answer is C

Answer: C. Methylergonovine 0.2 mg IM now.

A. Insert an indwelling urinary catheter.
Inserting an indwelling urinary catheter can be appropriate in a postpartum client, especially if there are concerns about bladder distension, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage. This action does not require clarification.

B. Administer oxygen by nonrebreather mask at 5 L/min.
Although oxygen is commonly delivered at higher rates (10-15 L/min) via a nonrebreather mask, the administration of oxygen at 5 L/min is not harmful. This may be based on the client’s current oxygen needs, but the flow rate might warrant a review.

C. Methylergonovine 0.2 mg IM now.
Methylergonovine is used to control postpartum hemorrhage, but it is contraindicated in clients with hypertension. This client has elevated blood pressure (146/94 mm Hg), and administering methylergonovine could further increase the risk of hypertensive complications. Therefore, this prescription requires clarification due to the risk of hypertensive crisis.

D. Obtain laboratory study of prothrombin and partial thromboplastin time.
Ordering coagulation studies such as prothrombin time (PT) and partial thromboplastin time (PTT) is appropriate, especially in a postpartum client with heavy bleeding, to assess clotting status and rule out any coagulation disorders. This prescription does not require clarification.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

Answer: B, C, D, E

Rationale:

A) Massage a firm fundus: If the fundus is already firm, routine massage is not necessary. Instead, the nurse should monitor the fundus for firmness and position. Massaging is indicated only if the fundus is boggy or atonic to promote uterine contraction.

B) Determine whether the fundus is midline: Checking the position of the fundus is essential to assess for potential complications. A fundus that is not midline could indicate bladder distention, which can interfere with uterine contraction and lead to postpartum hemorrhage.

C) Document fundal height: Documenting the height of the fundus is important for monitoring uterine involution. The fundus should be at the level of the umbilicus 1-2 hours postpartum, and any deviation from expected findings should be noted for ongoing assessment.

D) Observe the lochia during palpation of fundus: Observing lochia during fundal assessment helps identify potential complications such as excessive bleeding or clots. It is crucial for the nurse to monitor lochia in conjunction with fundal assessment to ensure appropriate postpartum recovery.

E) Administer methylergonovine maleate if the uterus is boggy: Methylergonovine is indicated for uterine atony (a boggy uterus) to promote uterine contractions and reduce the risk of postpartum hemorrhage. If the fundus is found to be boggy during assessment, administration of this medication should be anticipated.

A. Soft, edematous area on the scalp B. Poor sucking C. Facial edema D. Blue coloring of the hands and feet

Correct Answer is B

Explanation

B) Poor sucking:
Following a vacuum-assisted delivery, poor sucking can indicate potential neurological issues or birth trauma. It could suggest problems with cranial nerve function or other underlying conditions that need further evaluation by the provider.

A) Soft, edematous area on the scalp:
A soft, edematous area on the scalp is a common finding after a vacuum-assisted delivery due to the pressure exerted by the vacuum cup. This finding is expected and usually resolves without intervention.

C) Facial edema:
Facial edema is a common occurrence after a vacuum-assisted delivery due to the pressure exerted by the vacuum cup on the baby's face during delivery. It usually resolves within a few days without intervention.

D) Blue coloring of the hands and feet:
Blue coloring of the hands and feet, known as acrocyanosis, is a common finding in newborns and is not typically a cause for concern. It often resolves within a few hours to days after birth and does not require immediate intervention.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse. "Will my baby be okay?" Which of the following responses should the nurse offer?

A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?