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 A
Explanation
The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30
minutes old.
Choice B rationale
Birth weight can influence a newborn’s health, with low birth weight associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Choice C rationale
Gestational age can influence a newborn’s health, with preterm birth associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Choice D rationale
Fetal Undergrowth Anomaly (FUA) refers to a condition where a fetus does not grow at the expected rate during pregnancy. It can lead to various health problems for the newborn. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
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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