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 D
Explanation
Choice A rationale
Administering Vitamin K is an important step in newborn care as it helps with blood clotting and prevents a rare but serious bleeding disorder called Vitamin K Deficiency Bleeding.
However, it is not the immediate priority after ensuring a patent airway.
Choice B rationale
Administering eye prophylaxis, typically in the form of antibiotic ointment, is a standard procedure in newborn care to prevent neonatal conjunctivitis. However, this is not the immediate priority after ensuring a patent airway.
Choice C rationale
Placing an identification bracelet on the newborn is crucial for ensuring the baby’s safety and preventing mix-ups. However, this is not the immediate priority after ensuring a patent airway.
Choice D rationale
Drying the skin of the newborn is the priority action after ensuring a patent airway. This is because newborns are wet with amniotic fluid at birth, and they can lose heat quickly through evaporation if not dried immediately. This can lead to hypothermia, which can be dangerous for the newborn.
Correct Answer is A
Explanation
The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30 minutes old...... However, it is less immediately life-threatening compared to meconium aspiration syndrome...... However, it is less immediately life-threatening compared to meconium aspiration syndrome. . Glucose is the main source of fuel for the brain and the body. In a newborn baby, low blood sugar can happen for many reasons. . However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Choice E rationale
Jaundice due to color of amniotic fluid is not a recognized medical condition........................... However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.