A nurse is caring for a client who gave birth 2 hours ago.
The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?

Administer oxytocin infusion.

Evaluate the firmness of the uterus.

Initiate oxygen therapy by non-rebreather mask.

Obtain a type and crossmatch.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering oxytocin infusion is usually done to stimulate uterine contractions and prevent postpartum hemorrhage. However, it’s not the first action to take when the client’s blood pressure is low.

Choice B rationale
Evaluating the firmness of the uterus is crucial in this situation. A soft or “boggy” uterus could indicate uterine atony, a condition that can lead to serious postpartum hemorrhage. This could be the cause of the client’s low blood pressure.
Choice C rationale
Initiating oxygen therapy by non-rebreather mask can help increase the client’s oxygen saturation levels, but it doesn’t address the underlying cause of the low blood pressure.
Choice D rationale
Obtaining a type and crossmatch is important if the client needs a blood transfusion. However, it’s not the first action to take. The nurse should first assess for possible causes of the low blood pressure.

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Correct Answer is A

Explanation

Choice A rationale
When the fetal head is at 3+ station, it means that the baby’s head has moved down the birth canal and is very close to the vaginal opening. At this stage, the nurse should observe for crowning, which is when the widest part of the baby’s head can be seen at the vaginal opening. This is a critical time during labor, and the nurse needs to be prepared for the delivery of the baby.
Choice B rationale
Applying fundal pressure is not recommended as it can cause complications such as uterine rupture, fetal distress, and maternal discomfort. It is also not necessary when the fetal head is at 3+ station as the baby is already moving down the birth canal.
Choice C rationale
Oxytocin is a hormone that can stimulate uterine contractions. However, it is not necessary to prepare to administer oxytocin when the fetal head is at 3+ station. At this stage, the mother’s body is already effectively progressing through labor.
Choice D rationale

Observing for the presence of a nuchal cord, which is when the umbilical cord is wrapped around the baby’s neck, is important throughout labor. However, it is not the primary action the nurse should take when the fetal head is at 3+ station.

A. Assist with amnioinfusion. B. Insert a scalp electrode. C. Change the woman’s position. D. Notify the health care provider. E. Choice D rationale

Correct Answer is C

Explanation

Choice A rationale
Assisting with amnioinfusion is not the first priority. Amnioinfusion is a procedure where a sterile solution is introduced into the uterus to increase the volume of fluid around the fetus. It is typically used in cases of oligohydramnios (low amniotic fluid) or to dilute thick meconium in the amniotic fluid.
Choice B rationale
Inserting a scalp electrode is not the first priority. A scalp electrode is a device used to monitor the fetal heart rate more accurately. It is usually used when external monitoring does not provide a clear reading or when there is a need for continuous detailed monitoring.

Choice C rationale
Changing the woman’s position is the correct action. Late decelerations in the fetal heart rate can be a sign of uteroplacental insufficiency, a condition where the placenta cannot deliver adequate oxygen to the fetus. Changing the woman’s position can improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Notifying the health care provider is important but not the first priority. The nurse should first attempt interventions such as changing the woman’s position to improve the fetal heart rate.

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A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?

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Explanation

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Correct Answer is C

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A nurse is caring for a client who gave birth 2 hours ago.
The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?