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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Related Questions
Correct Answer is B
Explanation
Choice A reason: Blunt force trauma is a possible risk factor for placental abruption, which is a condition where the placenta detaches from the uterine wall and causes bleeding, pain, and fetal distress. However, blunt force trauma is not the most common risk factor, as it accounts for only a small percentage of cases. The most common causes of blunt force trauma are motor vehicle accidents, falls, or domestic violence.
Choice B reason: Hypertension is the most common risk factor for placental abruption, as it affects about 50% of cases. Hypertension can cause vasospasm and reduced blood flow to the placenta, which can weaken the attachment and lead to separation. Hypertension can be chronic, gestational, or related to preeclampsia.
Choice C reason: Gestational diabetes mellitus is not a risk factor for placental abruption, but rather a condition where the client develops high blood sugar levels during pregnancy and can cause complications, such as macrosomia, polyhydramnios, or neonatal hypoglycemia. Gestational diabetes mellitus does not affect the placental attachment or function.
Choice D reason: Cigarette smoking is a risk factor for placental abruption, as it can cause vasoconstriction and reduced oxygen delivery to the placenta, which can impair its growth and development. However, cigarette smoking is not the most common risk factor, as it affects about 25% of cases.
Correct Answer is C
Explanation
Choice A reason: Molar pregnancy is a risk factor for hyperemesis gravidarum, as it is a gestational trophoblastic disease that causes an abnormal growth of the placenta and the production of high levels of human chorionic gonadotropin (hCG), which is a hormone that stimulates nausea and vomiting. Molar pregnancy can cause severe and persistent hyperemesis gravidarum, as well as vaginal bleeding, uterine enlargement, and preeclampsia.
Choice B reason: Previous history of hyperemesis gravidarum is a risk factor for hyperemesis gravidarum, as it suggests a genetic or physiological predisposition to the condition. Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs in pregnancy, and it can cause dehydration, electrolyte imbalance, weight loss, and malnutrition. Hyperemesis gravidarum can recur in subsequent pregnancies, especially if the mother has the same partner, the same sex of the fetus, or a short interval between pregnancies.
Choice C reason: Oligohydramnios is not a risk factor for hyperemesis gravidarum, as it is a low level of amniotic fluid that surrounds the fetus. Oligohydramnios is not related to hyperemesis gravidarum, and it is not a cause or a consequence of it. Oligohydramnios can affect the fetal development and the delivery, as it can cause fetal growth restriction, cord compression, or meconium aspiration.
Choice D reason: Multiple fetal gestation is a risk factor for hyperemesis gravidarum, as it is a condition where the mother is carrying more than one fetus. Multiple fetal gestation can cause higher levels of hCG, estrogen, and progesterone, which are hormones that stimulate nausea and vomiting. Multiple fetal gestation can cause more severe and prolonged hyperemesis gravidarum, as well as preterm labor, anemia, and preeclampsia.
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