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: Primigravida in spontaneous labor with preterm twins is not at the greatest risk for early postpartum hemorrhage, as preterm births are associated with lower blood loss and smaller placentas. However, this client may have other complications, such as preterm labor, premature rupture of membranes, or fetal growth restriction.
Choice B reason: Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress is not at the greatest risk for early postpartum hemorrhage, as cesarean births are associated with higher blood loss and larger incisions. However, this client may have other complications, such as infection, wound dehiscence, or thromboembolism.
Choice C reason: Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor is at the greatest risk for early postpartum hemorrhage, as multiparity and rapid labor are both risk factors for uterine atony, which is the most common cause of early postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract and retract after delivery, and can cause excessive bleeding and hypovolemic shock.
Choice D reason: Woman with severe preeclampsia on magnesium sulfate whose labor is being induced is not at the greatest risk for early postpartum hemorrhage, as preeclampsia and magnesium sulfate are both risk factors for late postpartum hemorrhage, which occurs after 24 hours of delivery. However, this client may have other complications, such as eclampsia, HELLP syndrome, or placental abruption.
Correct Answer is A
Explanation
Choice A reason: Dipstick value of 3+ for protein in her urine is a sign of significant proteinuria, which is one of the diagnostic criteria for preeclampsia, along with hypertension. Proteinuria indicates renal damage and impaired glomerular filtration, which can lead to complications, such as oliguria, eclampsia, or HELLP syndrome.
Choice B reason: Pitting pedal edema at the end of the day is a common and expected finding in pregnancy, as it results from the increased blood volume, venous pressure, and fluid retention. Edema is not a reliable indicator of preeclampsia, unless it is severe, generalized, or sudden.
Choice C reason: Weight gain of 0.5 kg during the past 2 weeks is a normal and expected finding in pregnancy, as it reflects the growth and development of the fetus, placenta, and maternal tissues. Weight gain is not a reliable indicator of preeclampsia, unless it is excessive, rapid, or associated with edema.
Choice D reason: Blood pressure (BP) increase to 138/86 mm Hg is a mild elevation that may indicate gestational hypertension, but not preeclampsia, unless it is accompanied by proteinuria or other signs of organ dysfunction. The diagnostic threshold for preeclampsia is a BP of 140/90 mm Hg or higher on two occasions at least four hours apart.
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