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:
Freezing embryos for future use is a personal decision and not something a nurse should instruct a client to avoid.
Choice B rationale:
In vitro fertilization can result in multiple pregnancies, and reduction of multiple fetuses may be necessary for the health of the mother and the remaining fetuses.
Choice C rationale:
The use of donor oocytes is a personal decision and not something a nurse should instruct a client to avoid.
Choice D rationale:
In in vitro fertilization, sperm is introduced to the egg in a laboratory, not the uterus.
Correct Answer is D
Explanation
Choice A rationale:
A depressed anterior fontanel is not typically caused by forceps-assisted birth. It can indicate dehydration or intracranial pressure.
Choice B rationale:
Uneven gluteal skinfolds could suggest developmental dysplasia of the hip, not a forceps injury.
Choice C rationale:
Epicanthal folds are a normal characteristic in many populations and are not related to birth injuries.
Choice D rationale:
Facial asymmetry can occur due to pressure from the forceps on the facial nerves during delivery.
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