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. Which of the following actions should the nurse take first?
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
Evaluate the firmness of the uterus.
The Correct Answer is D
Choice A reason: Obtaining a type and crossmatch is not the first action that the nurse should take, as it is a preparatory step for blood transfusion, which may or may not be needed. The nurse should first identify the cause and severity of the hypotension, and initiate immediate interventions to stop the bleeding and restore the circulation.
Choice B reason: Administering oxytocin infusion is not the first action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the uterine tone and bleeding. The nurse should first evaluate the firmness of the uterus and massage it if needed, to stimulate the contraction and retraction of the uterine muscle.
Choice C reason: Initiating oxygen therapy by nonrebreather mask is not the first action that the nurse should take, as it is a supportive intervention that aims to improve the oxygen delivery to the tissues and organs. The nurse should first address the underlying cause of the hypotension, which is most likely postpartum hemorrhage, and prevent further blood loss and shock.
Choice D reason: Evaluating the firmness of the uterus is the first action that the nurse should take, as it can help determine the source and extent of the bleeding, and guide the subsequent interventions. The nurse should palpate the fundus and check the lochia, and report any signs of uterine atony, which is the most common cause of postpartum hemorrhage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Nervousness is a common and expected side effect of terbutaline, which is a beta-2 adrenergic agonist that stimulates the sympathetic nervous system and relaxes the uterine smooth muscle. The nurse does not need to report this finding to the provider, but can provide reassurance and comfort to the client.
Choice B reason: Tremors are also a common and expected side effect of terbutaline, as it causes increased muscle activity and shakiness. The nurse does not need to report this finding to the provider, but can monitor the client's vital signs and electrolyte levels, and advise the client to avoid caffeine and other stimulants.
Choice C reason: Dyspnea is an uncommon and serious side effect of terbutaline, as it can indicate pulmonary edema, which is a life-threatening condition where fluid accumulates in the lungs and impairs gas exchange. The nurse should report this finding to the provider immediately and prepare for interventions, such as oxygen therapy, diuretics, or discontinuation of terbutaline.
Choice D reason: Headaches are also a common and expected side effect of terbutaline, as it causes vasodilation and increased blood flow to the brain. The nurse does not need to report this finding to the provider, but can administer analgesics as prescribed, and encourage the client to rest and hydrate.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible cause of it. Polyhydramnios is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can occur in multiple pregnancies, as the fetuses produce more urine and fluid than a single fetus.
Choice B reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible complication of it. Polyhydramnios can cause fetal anomalies, such as esophageal atresia, anencephaly, or neural tube defects, which impair the swallowing or absorption of the amniotic fluid. Polyhydramnios can also cause fetal growth restriction or distress, as the excess fluid can compress the umbilical cord or the placenta, and reduce the blood flow and oxygen delivery to the fetus.
Choice C reason: This statement is correct, as it is the definition of polyhydramnios, which is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can be diagnosed by ultrasound, and it can cause maternal and fetal complications, such as preterm labor, premature rupture of membranes, placental abruption, or cord prolapse.
Choice D reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a marker of fetal anomalies. Alpha-fetoprotein (AFP) is a protein that is produced by the fetus, and it can be measured in the maternal serum or the amniotic fluid. An elevated level of AFP in the amniotic fluid can indicate fetal anomalies, such as neural tube defects, abdominal wall defects, or renal anomalies, which can cause polyhydramnios.
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