A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.
Which of the following actions should the nurse take first?
Collect hemoglobin and hematocrit levels.
Insert an indwelling urinary catheter.
Administer oxygen via face mask at 10 L/min.
Prepare the client to receive a plasma expander.
The Correct Answer is A
Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Removing the diaphragm 2 to 4 hours after intercourse is incorrect because the diaphragm should be left in place for at least 6 hours after intercourse to prevent pregnancy.
Choice B rationale:
Inserting the diaphragm up to 6 hours before intercourse is correct. This allows time for the spermicide to become effective.
Choice C rationale:
Washing the diaphragm with detergent soap between uses is incorrect. Detergent soap can degrade the material of the diaphragm.
Choice D rationale:
Applying a vaginal lubricant to the diaphragm prior to insertion is incorrect. Lubricants can interfere with the effectiveness of the spermicide.
Correct Answer is D
Explanation
Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
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.