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
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. This sign is commonly seen in early pregnancy, but it does not indicate the presence of blood in the peritoneum.
Choice B rationale
Chvostek’s sign is a clinical sign of existing nerve hyperexcitability seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. This sign is not related to a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascular softening is seen in early pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Cullen’s sign is the appearance of bruising in the skin around the umbilicus. It occurs when there is blood in the peritoneum, or intra-abdominal bleeding. In the case of a suspected ruptured ectopic pregnancy, Cullen’s sign would indicate the presence of blood in the peritoneum.
Correct Answer is C
Explanation
The correct answer is choice C: Respiratory rate.
Choice A rationale:
Fetal heart rate (FHR) is an important assessment for clients experiencing preterm labor, but it is not the priority assessment when administering magnesium sulfate. FHR monitoring is crucial to ensure fetal well-being but is not directly related to the potential adverse effects of magnesium sulfate.
Choice B rationale:
Temperature is an essential assessment parameter, but it is not the priority in this case. Magnesium sulfate administration can cause adverse effects, particularly on the respiratory system, which should be closely monitored.
Choice C rationale:
Respiratory rate is the correct choice because respiratory rate is a priority assessment when administering magnesium sulfate. The drug can cause respiratory depression and other respiratory complications, so monitoring the respiratory rate is essential to ensure the client's safety.
Choice D rationale:
Bowel sounds are not a priority assessment for a client receiving magnesium sulfate. While gastrointestinal side effects can occur with magnesium sulfate use, respiratory assessments take precedence.
In conclusion, the priority nursing assessment for a client receiving magnesium sulfate is the respiratory rate due to the potential respiratory complications associated with the drug. Monitoring respiratory function closely can help prevent adverse outcomes and ensure the client's safety during treatment.
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