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: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.
Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.
Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.
Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.
Correct Answer is D
Explanation
Choice A reason: Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation and pain. The risk factors for thrombophlebitis include immobility, dehydration, obesity, smoking, and cesarean birth. This client is not at increased risk for thrombophlebitis based on the information given.
Choice B reason: Retained placental fragments are pieces of the placenta that remain in the uterus after delivery and can cause bleeding, infection, or uterine subinvolution. The risk factors for retained placental fragments include placenta previa, placenta accreta, manual removal of the placenta, and incomplete separation of the placenta. This client is not at increased risk for retained placental fragments based on the information given.
Choice C reason: Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery and can cause fever, malaise, abdominal pain, and foul-smelling lochia. The risk factors for puerperal infection include prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, operative delivery, and retained placental fragments. This client is not at increased risk for puerperal infection based on the information given.
Choice D reason: Uterine atony is a condition where the uterus fails to contract and retract after delivery and can cause excessive bleeding, hypovolemic shock, and hemorrhage. The risk factors for uterine atony include overdistension of the uterus, prolonged labor, oxytocin use, anesthesia, and trauma. This client is at increased risk for uterine atony due to the large size of the newborn, which can overstretch the uterus and impair its ability to contract.
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