A nurse is caring for a client who gave birth 2 hr ago.

The nurse notes that the client’s blood pressure is 60/50 mm Hg. What is the first action the nurse should take?

Evaluate the firmness of the uterus.

Oxygenate by rebreather mask.

Administer oxytocin infusion.

Obtain a type and crossmatch.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Evaluating the firmness of the uterus is the first action the nurse should take when a client’s blood pressure is 60/50 mm Hg after giving birth. A soft or “boggy” uterus can indicate uterine atony, a condition in which the uterus fails to contract after birth. Uterine atony can lead to significant postpartum hemorrhage, which can cause hypotension.
Choice B rationale
Oxygenating by rebreather mask may be necessary if the client shows signs of hypoxia or difficulty breathing, but it is not the first action the nurse should take.
Choice C rationale
Administering oxytocin infusion can stimulate uterine contractions and help control postpartum bleeding. However, the nurse should first assess the firmness of the uterus.
Choice D rationale
Obtaining a type and crossmatch may be necessary if the client needs a blood transfusion, but it is not the first action the nurse should take.

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Correct Answer is C

Explanation

Choice A rationale
While it’s true that some changes in the breast, such as dimpling or discharge, can occur with age, these are not normal and could be signs of a serious condition like breast cancer.
Therefore, this instruction should not be included in the pamphlet.
Choice B rationale
While using the palm of the hand to feel for lumps using a circular motion is a common method, it’s not the most effective. The pads of the three middle fingers should be used instead, as they are more sensitive to changes in the breast tissue.
Choice C rationale
This is the correct answer. Performing a breast self-exam in the shower with soapy hands is recommended because the soap helps your fingers glide smoothly over your skin, making it easier to feel for any lumps or changes.
Choice D rationale
While it’s true that women who have a menstrual cycle should perform a breast self-exam every month, the timing suggested here is not accurate. The best time to perform a breast self- exam is a few days after the menstrual period ends, when the breasts are less likely to be tender or swollen.

A. “This test will indicate if your child has rheumatic fever.”. B. “This test will confirm if your child had a recent streptococcal infection.”. C. “This test will indicate if your child has a therapeutic blood level of an aminoglycoside.”. D. “This test will confirm if your child has immunity to streptococcal bacteria.”.

Correct Answer is B

Explanation

Choice A rationale
While an ASO titer test can be used in the diagnosis of rheumatic fever, it does not directly indicate if a child has rheumatic fever. Rheumatic fever is a complication that can occur after a streptococcal infection, and it involves multiple systems in the body, not just the presence of streptococcal antibodies.
Choice B rationale
An ASO titer test measures the antibodies produced by your body in response to a toxin known as streptolysin O, which is produced by group A Streptococcus (GAS) bacteria. Your body makes the antistreptolysin O antibodies when you have a strep infection caused by GAS bacteria. Therefore, a positive ASO titer test can confirm if your child had a recent streptococcal infection.
Choice C rationale
An ASO titer test does not measure the blood level of an aminoglycoside or any other therapeutic drug. Aminoglycosides are a class of antibiotics used to treat bacterial infections, and their levels in the blood are typically monitored with specific drug level tests, not an ASO titer.
Choice D rationale
An ASO titer test does not confirm if your child has immunity to streptococcal bacteria. The presence of ASO antibodies indicates a recent infection, but it does not provide information about the immune status or protection against future infections.

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A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What is the first action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. What should the nurse respond?

Correct Answer is B

Explanation

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A nurse is caring for a client who gave birth 2 hr ago.

The nurse notes that the client’s blood pressure is 60/50 mm Hg. What is the first action the nurse should take?