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 C
Explanation
Choice A rationale
Drying the infant off and covering the head is important to prevent heat loss, but it is not the first action to be taken. The newborn’s body temperature can drop rapidly because of the evaporation of amniotic fluid, so drying the infant is a priority, but not the first one.
Choice B rationale
Stimulating the infant to cry is important as it helps to clear the lungs of amniotic fluid and promotes the expansion of the lungs for effective oxygenation. However, this is not the first action to be taken. The first action is to clear the respiratory tract.
Choice C rationale
Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly. This is done by suctioning the mouth first and then the nose to prevent aspiration of mucus or amniotic fluid, which can lead to respiratory distress.
Choice D rationale
Cutting the umbilical cord is done after the newborn’s respiratory status is stable. It is not the first action to be taken. The umbilical cord is usually clamped and cut by the healthcare provider after it has stopped pulsating, or after the newborn has started to breathe on their own.
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