A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin.The client reports that they have been bleeding excessively.
Which of the following actions should the nurse take?
Elevate the head of the client's bed.
Administer a dose of terbutaline.
Initiate oxygen at 2 L/min via nasal cannula.
Initiate an infusion of oxytocin.
The Correct Answer is D
Choice A rationale
Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.
Choice B rationale
Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.
Choice C rationale
Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.
Choice D rationale
Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Holding the newborn during the initial visit may make the older sibling feel left out or jealous. Encouraging involvement with the new baby may be more beneficial.
Choice B rationale
Spending individual time with the older sibling helps them feel valued and ensures they do not feel neglected, facilitating better acceptance of the newborn.
Choice C rationale
Having the older sibling purchase a gift for the newborn can create a positive association, but it is less impactful than ensuring individual time and attention.
Choice D rationale
Postponing the introduction until discharge can increase feelings of jealousy or resentment, as the older sibling might feel excluded from the new family dynamic during a crucial time.
Correct Answer is A
Explanation
The nurse should identify that contractions occurring every 5 minutes require follow-up for several reasons:
- Preterm Labor Risk: At 32 weeks of gestation, regular contractions every 5 minutes could indicate the onset of preterm labor. This is concerning because preterm labor can lead to preterm birth, which poses significant risks to the baby's health and development.
- Frequency and Intensity: These contractions are occurring frequently (every 5 minutes) and are described as stronger than usual Braxton Hicks contractions. This frequency and the strength of the contractions are unusual for Braxton Hicks, which are typically irregular and less intense.
- Effacement and Cervical Changes: Although the cervix is closed, it is 80% effaced. Effacement means the cervix is thinning, which, in combination with regular contractions, may indicate that the body is preparing for labor.
- Urinary Leakage: The client also reported urinary leakage earlier in the day, which could be a sign of ruptured membranes (water breaking). This, combined with regular contractions, increases the need for careful monitoring.
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