A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?
Evaluate the firmness of the uterus.
Administer oxytocin infusion.
Obtain a type and crossmatch.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
Choice A rationale
If a nurse notes that a client’s blood pressure is 60/50 mm Hg two hours after giving birth, the first action should be to evaluate the firmness of the uterus. This is because a soft or “boggy” uterus could indicate uterine atony, a condition where the uterus fails to contract after delivery, leading to excessive bleeding and a drop in blood pressure.
Choice B rationale
Administering oxytocin infusion can help stimulate uterine contractions and control postpartum bleeding. However, it is not the first action to take. The nurse should first assess the firmness of the uterus.
Choice C rationale
Obtaining a type and crossmatch is important if a blood transfusion is required. However, this is not the first action. The nurse should first assess the firmness of the uterus.
Choice D rationale
Initiating oxygen therapy can help ensure adequate oxygen supply to the tissues, but it is not the first action. The nurse should first assess the firmness of the uterus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Swaddling a newborn can provide comfort and help soothe them. However, it is not a specific treatment for a Neonatal Abstinence Scoring System (NAS) score of 201.
Choice B rationale
Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. It is not typically administered for NAS unless the newborn is experiencing life-threatening respiratory depression due to opioid exposure. Moreover, it is not specifically indicated for NAS scores greater than 241.
Choice C rationale
Continuing NAS scoring as prescribed is important for monitoring the newborn’s condition. However, a score of 20 indicates significant withdrawal symptoms, which may require more than just monitoring.
Choice D rationale
Administering oral morphine is a common treatment for NAS. Morphine, an opioid medication, is used to manage withdrawal symptoms in newborns with NAS. The goal is to control symptoms and then gradually wean the newborn off the medication.
Correct Answer is D
Explanation
The correct answer is choiced. Slightly above the umbilicus.
Choice A rationale:
At 22 weeks of gestation, the fundus is not typically 5 cm above the umbilicus. This measurement would be more consistent with a later stage of pregnancy, around 28 weeks.
Choice B rationale:
The fundus being slightly below the umbilicus is more consistent with an earlier stage of pregnancy, around 20 weeks. At 22 weeks, the fundus should be higher.
Choice C rationale:
The fundus being 3 cm below the umbilicus is also indicative of an earlier stage of pregnancy, not 22 weeks. This would be expected around 18-20 weeks.
Choice D rationale:
At 22 weeks of gestation, the fundus is typically located slightly above the umbilicus.This corresponds with the general rule that the fundal height in centimeters should match the number of weeks of pregnancy, give or take 2 cm.
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