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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
The patient’s anti-A and anti-B antibodies crossing the placenta and causing the destruction of the fetal red blood cells is related to ABO incompatibility, not Rh incompatibility.
Choice B rationale
If the patient’s blood contains the Rh factor and the newborn’s does not, Rh incompatibility would not occur. Rh incompatibility happens when the mother’s blood does not contain the Rh factor (Rh-negative), but the baby’s blood does contain the Rh factor (Rh-positive).
Choice C rationale
The patient’s blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. This is the correct reason for hyperbilirubinemia occurring with Rh incompatibility.
Choice D rationale
The patient’s blood containing anti-Rh antibodies that attack the newborn’s red blood cells is a result of Rh incompatibility, but it does not explain why hyperbilirubinemia occurs.
Hyperbilirubinemia occurs due to the breakdown of the extra red blood cells, leading to an increase in bilirubin levels.
Correct Answer is A
Explanation
Choice A rationale
The nurse’s response, “You seem scared to talk to your parents,” is an empathetic response that validates the client’s feelings and encourages further communication. It’s important for the nurse to provide emotional support and help the client explore her feelings about the situation. The nurse can also provide information about confidentiality laws and discuss potential outcomes of various decisions.
Choice B rationale
Telling the client that her parents will have to be told why she is being admitted may not be accurate depending on the age of the client and local laws regarding minor’s rights to privacy in healthcare. It’s crucial to respect the client’s autonomy and privacy.
Choice C rationale
While it’s possible that the parents might understand, suggesting this puts pressure on the client to disclose her condition to her parents. The nurse should instead focus on supporting the client in making her own decision about disclosure.
Choice D rationale
Offering to tell the parents for the client could undermine the client’s autonomy and may not be legally permissible without the client’s consent. The nurse should instead focus on helping the client explore her options and come to her own decision.
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