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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Terbutaline does not typically cause a decrease in maternal blood glucose levels. It is a medication used to relax the muscles in the uterus to prevent premature labor.
Choice B rationale
Terbutaline does not enhance the production of fetal lung surfactant. It is used to relax the muscles in the uterus to prevent premature labor.
Choice C rationale
Weakened uterine contractions are an expected finding in a client who has received terbutaline. Terbutaline is a tocolytic medication, which means it works to inhibit uterine contractions in order to prevent or halt preterm labor.
Choice D rationale
Terbutaline does not typically cause a decrease in fetal heart rate. It is used to relax the muscles in the uterus to prevent premature labor.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
The G in GTPAL stands for gravida, which is the number of times an individual has conceived, including any current pregnancy. In this case, G3 means the client has had three pregnancies, which includes two prior pregnancies and the current one.
Choice B rationale
The client’s record does not indicate that she is currently pregnant with twins, making this choice incorrect.
Choice C rationale
The A in GTPAL stands for the number of abortions, which refers to all times the individual has lost a pregnancy before 20 weeks. In this case, A1 means the client has had one abortion, indicating a risk for miscarriage.
Choice D rationale
The T in GTPAL stands for term births, which refers to the number of times an individual has carried a pregnancy to at least 37 weeks of gestation and delivered. In this case, T1 means the client has had one full-term birth.
Choice E rationale
The L in GTPAL stands for living children. In this case, L1 means the client has one living child.
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