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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:
Subcutaneous injections are not typically used for newborns due to their lack of subcutaneous fat.
Choice B rationale:
The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and location.
Choice C rationale:
The deltoid is not a recommended site for IM injections in newborns due to its small size.
Choice D rationale:
As mentioned earlier, subcutaneous injections are not typically used for newborns.

A. "This medication increases cardiac output.”. B. "This medication prevents seizures.”. C. "This medication stabilizes the fetal heart rate.”. D. "This medication improves tissue perfusion.”.

Correct Answer is B

Explanation

Choice A rationale:
Magnesium sulfate does not increase cardiac output. It is a central nervous system depressant and muscle relaxant.
Choice B rationale:
Magnesium sulfate is given to clients with preeclampsia to prevent seizures, which can be a complication of this condition.
Choice C rationale:
Magnesium sulfate does not directly stabilize the fetal heart rate. Its primary use in preeclampsia is seizure prevention.
Choice D rationale:
While magnesium sulfate can cause vasodilation, which could improve tissue perfusion, its primary use in preeclampsia is to prevent seizures.

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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?

Nursing Test Bank

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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?