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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: She is exhibiting hypertonic uterine dysfunction, because she has frequent and painful contractions that are ineffective in dilating the cervix. Hypertonic uterine dysfunction occurs when the uterus contracts too often and too forcefully, resulting in poor oxygenation and fetal distress. The woman may need tocolytic therapy, pain relief, and hydration.
Choice B reason: She is not experiencing a normal latent stage, because her contractions are too frequent and too painful for this phase of labor. The normal latent stage is characterized by irregular and mild contractions that gradually increase in frequency and intensity, and cervical dilation from 0 to 3 cm.
Choice C reason: She is not experiencing precipitous labor, because her labor is not progressing rapidly. Precipitous labor is defined as labor that lasts less than 3 hours from the onset of contractions to the delivery of the baby. It is associated with cervical dilation of more than 5 cm per hour.
Choice D reason: She is not exhibiting hypotonic uterine dysfunction, because her contractions are not weak or infrequent. Hypotonic uterine dysfunction occurs when the uterus contracts too weakly or too rarely, resulting in prolonged labor and increased risk of infection. The woman may need oxytocin augmentation, amniotomy, or cesarean section.
Correct Answer is B
Explanation
Choice A reason: Placing the newborn in Trendelenburg position is not an appropriate nursing action, as it can cause increased intracranial pressure, decreased lung expansion, and aspiration. The nurse should position the newborn in a neutral or slightly elevated head position, with the neck slightly extended.
Choice B reason: Maintaining oxygen saturations between 93% to 95% is an appropriate nursing action, as it ensures adequate oxygen delivery to the tissues and organs, while avoiding hyperoxia or hypoxia, which can cause complications, such as retinopathy of prematurity, intraventricular hemorrhage, or necrotizing enterocolitis.
Choice C reason: Inserting an orogastric tube for decompression of the stomach is not an appropriate nursing action, as it is not indicated for oxygen hood therapy, unless the newborn has abdominal distension, vomiting, or feeding intolerance. The nurse should monitor the newborn's abdominal girth, bowel sounds, and feeding tolerance, and report any signs of gastrointestinal dysfunction.
Choice D reason: Removing the hood every hour for 10 min to facilitate bonding is not an appropriate nursing action, as it can cause fluctuations in the oxygen concentration and temperature, and increase the risk of infection. The nurse should maintain the hood in place, and encourage the parents to touch, talk, and sing to the newborn, and provide skin-to-skin contact when possible.
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