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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Early decelerations in the fetal heart rate (FHR) are caused by compression of the fetus’s head during a uterine contraction. This often happens during later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position. This causes the uterus to squeeze the head during contractions.
Choice B rationale
Uteroplacental insufficiency is a condition where the placenta does not provide enough oxygen and nutrients to the fetus. This condition is typically associated with late decelerations in the FHR, not early decelerations.
Choice C rationale
Altered fetal cerebral blood flow is not typically associated with early decelerations in the FHR34.
Choice D rationale
Umbilical cord compression is typically associated with variable decelerations in the FHR, not early decelerations.
Correct Answer is D
Explanation
Choice A rationale
Placing pillows under the patient’s knees when resting in bed can actually increase the risk of thromboembolic disease by slowing blood flow and promoting clot formation.
Choice B rationale
Massaging the patient’s posterior lower legs is not recommended, especially if the patient is showing signs of a possible deep vein thrombosis (DVT), as it could dislodge a clot.
Choice C rationale
Applying warm, moist heat to the patient’s lower extremities is not typically recommended as a primary intervention for patients with a history of thromboembolic disease.
Choice D rationale
Having the patient ambulate can help prevent the formation of blood clots by promoting blood circulation.
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