A nurse is assisting with the care of a client who gave birth.
After review of the medical record of the client, the nurse notes concerning data collection findings.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition:
Uterine atony
Boggy uterus, heavy bleeding, fundus responds to massage but returns to boggy state.
Actions to Take:
Massage fundus.
First-line measure to stimulate contraction and reduce bleeding.
Administer IV oxytocin.
Oxytocin promotes uterine contractions to reduce bleeding.
Parameters to Monitor:
Amount of lochia.
Helps assess ongoing blood loss.
Urine output.
Indicates perfusion status and potential hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The task involves making ongoing judgments about client data.
APs cannot assess or make clinical judgments—this is a nursing responsibility.
B. The task is within the AP’s range of function.
This supports delegation, not contraindicates it.
C. The task can be performed in the same manner...
Predictable tasks can be delegated if routine.
D. The task requires a specific sequence of steps.
This is acceptable if steps are standard and not based on nursing judgment.
Correct Answer is ["A","C","D","F"]
Explanation
A. Respiratory rate
Increased to 28/min from baseline of 18/min. This may indicate respiratory distress or pulmonary embolism.
B. Pedal pulses
Still 2+, no change noted - not an immediate concern.
C. Breath sounds
Crackles at the bases are new and could suggest fluid overload, atelectasis, or early pneumonia/PE.
D. Oxygen saturation
Dropped to 88% on room air, indicating hypoxia, which requires urgent intervention.
E. Movement of right foot
No change - sensation and movement intact, not an urgent issue.
F. Heart rate
Increased from 88 to 112/min. Can indicate pain, infection, or respiratory compromise.
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