A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?

Explain the procedure for an upper gastrointestinal series

Administer pain medication

Assess orthostatic blood pressure

Test the client’s emesis for blood .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Explaining the procedure for an upper gastrointestinal series is important for a client diagnosed with gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice B rationale

Administering pain medication is important for a client’s comfort, but it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

Choice C rationale

Assessing orthostatic blood pressure is the first action a nurse should take when caring for a client diagnosed with gastrointestinal bleeding. Orthostatic hypotension (a drop in blood pressure when standing up from a sitting or lying position) can be a sign of significant blood loss. This assessment helps determine the severity of the bleeding and guides further interventions.

Choice D rationale

Testing the client’s emesis for blood is an important part of diagnosing and managing gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.

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Correct Answer is B

Explanation

Choice A rationale

The term “passenger” in the context of the 5 P’s of labor refers to the fetus. The size, presentation, and position of the fetus can all affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the fetus, so this is not the correct answer.

Choice B rationale

The term “passageway” refers to the birth canal, which includes the pelvis. The size and shape of the pelvis can greatly impact the progress of labor. If the provider comments that there is “plenty of room in the pelvis,” they are likely referring to the passageway. Therefore, this is the correct answer.

Choice C rationale

The term “powers” refers to the contractions during labor. The frequency, duration, and intensity of contractions can affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to contractions, so this is not the correct answer.

Choice D rationale

The term “position” refers to the mother’s position during labor. Different positions can help facilitate the progress of labor and can help with pain management. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the mother’s position, so this is not the correct answer.

A. Have the patient void. B. Ask the patient if she needs pain medication. C. Turn the patient on her side and recheck the blood pressure. D. Notify the healthcare provider of the findings.

Correct Answer is C

Explanation

Choice A rationale

Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.

Choice B rationale

Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.

Choice C rationale

Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.

Choice D rationale

Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.

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A nurse is caring for a client diagnosed with gastrointestinal bleeding.Which of the following actions should the nurse take first?

Nursing Test Bank

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Correct Answer is B

Explanation

Correct Answer is C

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A nurse is caring for a client diagnosed with gastrointestinal bleeding.
Which of the following actions should the nurse take first?