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
Applying cold compresses 20 minutes before each feeding may not be the most effective way to manage breast engorgement. Cold compresses can help to reduce swelling and relieve pain, but they do not address the underlying cause of engorgement, which is the accumulation of milk in the breasts.
Choice B rationale
Drinking herbal tea to reduce engorgement is not a proven method. While some herbs are believed to have galactagogue properties (increase milk production), they do not directly address breast engorgement. Furthermore, the safety and efficacy of many herbal remedies are not well-studied, and some may have side effects.
Choice C rationale
Letting the baby drain one breast at each feeding can help to alleviate engorgement, but it may not be sufficient if the feedings are spaced too far apart. The breasts continue to produce milk between feedings, and if the milk is not removed, engorgement can occur.
Choice D rationale
Feeding the baby every 2 hours can help to manage breast engorgement. Regular feedings help to ensure that the milk is being removed from the breasts, preventing the buildup that leads to engorgement.
Correct Answer is D
Explanation
Choice A rationale
Obtaining rectal temperatures is not recommended for newborns with spinal bifida. This is because the rectal route can introduce bacteria into the body, which can lead to infection.
Additionally, the rectal route may not provide an accurate temperature reading for these newborns.
Choice B rationale
Covering the lesion with a dry dressing is not recommended for newborns with spinal bifida. The lesion should be kept moist to prevent drying and cracking, which can lead to infection.
Choice C rationale
Applying snug clean diapers is not recommended for newborns with spinal bifida. This is because the pressure from the diaper can damage the exposed nerves and tissues in the lesion area.
Choice D rationale
Placing the newborn in the prone position is recommended for newborns with spinal bifida. This position helps to minimize pressure on the lesion and reduces the risk of trauma and infection.
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