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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.
Correct Answer is A
Explanation
Choice A rationale
The recommended time for rubella immunization for a woman who does not have immunity is shortly after giving birth. The MMR vaccine, which protects against measles, mumps, and rubella, is a live virus vaccine and is not recommended during pregnancy.
Choice B rationale
While it’s important for a woman to have immunity to rubella before her next pregnancy, waiting until her next attempt to get pregnant to get the vaccine could potentially leave her unprotected if she becomes pregnant sooner than planned.
Choice C rationale
The MMR vaccine is not recommended during pregnancy, including in the third trimester.
Choice D rationale
The MMR vaccine is not recommended during pregnancy, including in the second trimester.
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