A nurse is assisting with the care of a client who is experiencing a postpartum hemorrhage. Which of the following actions should the nurse take? (Select all that apply.).

Firmly massage the fundus.

Administer oxygen via a nonrebreather face mask.

Ensure the client has IV access.

Prepare the client for an amnioinfusion.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

The nurse should firmly massage the fundus. The rationale behind this action is that massaging the fundus helps to stimulate uterine contractions, which aids in controlling bleeding after childbirth. By promoting uterine contractions, the nurse can assist in preventing further hemorrhage.

Choice B reason:

The nurse should administer oxygen via a nonrebreather face mask. The rationale for this action is that postpartum hemorrhage can lead to decreased oxygen levels in the blood, which can be detrimental to both the mother and the baby. Providing oxygen via a nonrebreather face mask ensures adequate oxygenation and helps stabilize the client's condition.

Choice C reason:

The nurse should ensure the client has IV access. Establishing IV access is crucial in managing postpartum hemorrhage as it allows for the rapid administration of fluids, blood products, and medications. IV access ensures that the client receives prompt treatment to address the blood loss and stabilize her condition.

Choice D reason:

The nurse should not prepare the client for an amnioinfusion in the context of postpartum hemorrhage. An amnioinfusion is a procedure used during labor to infuse fluid into the amniotic sac. However, it is not indicated or relevant in the management of postpartum hemorrhage.

Choice E reason:

The nurse should give the client Rh (D) immune globulin. The rationale behind this action is that Rh (D) immune globulin, also known as RhoGAM, is administered to Rh-negative mothers after the birth of an Rh-positive baby. This prevents the mother's immune system from developing antibodies against Rh-positive blood cells, which could cause complications in future pregnancies.

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Correct Answer is B

Explanation

Choice A reason:

The nurse should not initiate contact precautions for a child with suspected epiglottitis. Epiglottitis is primarily caused by Haemophilus influenzae type B, and it spreads through respiratory droplets. Contact precautions are not necessary as the transmission occurs through droplets, and standard precautions should be sufficient.

Choice B reason:

The nurse should monitor pulse oximetry. Epiglottitis is a condition where the epiglottis becomes inflamed and swollen, potentially blocking the airway. Monitoring the child's pulse oximetry helps assess their oxygen saturation levels, which is crucial in determining if there is adequate oxygenation. If the oxygen saturation drops significantly, immediate intervention might be needed to maintain the child's airway and prevent hypoxia.

Choice C reason:

Obtaining a throat culture is not an appropriate intervention for suspected epiglottitis. In cases of suspected epiglottitis, the priority is to ensure the child's airway is maintained and that they receive appropriate medical attention promptly. Throat culture collection involves swabbing the throat to identify the infectious agent and is not a priority in this urgent situation.

Choice D reason:

Administering epinephrine IM is not indicated for suspected epiglottitis. Epinephrine is typically used to treat severe allergic reactions (anaphylaxis) and not for managing epiglottitis. The primary focus in epiglottitis is securing the airway and providing appropriate medical treatment, which might include antibiotics and respiratory support.

A. Breast changes. B. Ballottement. C. Urinary frequency. D. Nausea.

Correct Answer is ["A","C","D"]

Explanation

Choice A reason:

Breast changes are considered a presumptive sign of pregnancy. This means they are subjective indications reported by the woman and may not be definitive evidence of pregnancy. During pregnancy, the woman's breasts may undergo various changes such as tenderness, enlargement, and darkening of the areolas. These changes are primarily due to hormonal fluctuations and increased blood flow to the breast tissue.

Choice B reason:

Ballottement is not a presumptive sign of pregnancy. Ballottement is a clinical maneuver performed by a healthcare provider to assess the mobility of the fetus in the amniotic fluid. It involves tapping on the cervix and feeling for a rebound from the floating fetus. While it is an indication of pregnancy, it is not considered a presumptive sign as it requires a trained professional to detect.

Choice C reason:

Urinary frequency is a presumptive sign of pregnancy. During pregnancy, the growing uterus can put pressure on the bladder, leading to increased urinary frequency. However, urinary frequency can also be caused by other factors such as urinary tract infections, so it is not a definitive sign of pregnancy.

Choice D reason:

Nausea, specifically morning sickness, is a presumptive sign of pregnancy. Many pregnant women experience nausea and vomiting, especially during the first trimester, due to hormonal changes. However, nausea can also be caused by various other conditions, making it a presumptive rather than a confirmatory sign of pregnancy.

Choice E:

A positive pregnancy test is a probable sign of pregnancy rather than a presumptive sign. Pregnancy tests detect the presence of human chorionic gonadotropin (hCG), a hormone produced during pregnancy. A positive test provides strong evidence of pregnancy, but it is not considered a presumptive sign as it is an objective finding rather than a subjective symptom reported by the woman.

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A nurse is assisting with the care of a client who is experiencing a postpartum hemorrhage. Which of the following actions should the nurse take? (Select all that apply.).

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is ["A","C","D"]

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