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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Hypoglycemia is a low blood sugar level that can affect newborns, especially those who are premature, small for gestational age, or have diabetic mothers. However, hypoglycemia does not explain the high FHR, the low Apgar scores, or the pale and tachypneic appearance of the newborn.

Choice B reason: Phrenic nerve injury is a rare complication of cesarean section that can cause diaphragmatic paralysis and respiratory distress in the newborn. However, phrenic nerve injury usually affects only one side of the chest, and does not cause high FHR, low Apgar scores, or pallor.

Choice C reason: Sepsis is a serious infection that can affect newborns, especially those who are exposed to prolonged rupture of membranes, as in this case. Sepsis can cause high FHR, low Apgar scores, pale and tachypneic appearance, and other signs of shock and organ failure.

Choice D reason: Meconium aspiration syndrome is a condition where the newborn inhales meconium-stained amniotic fluid into the lungs, causing respiratory distress. However, meconium aspiration syndrome usually occurs in term or post-term infants, and is associated with low FHR, not high FHR. Meconium aspiration syndrome also causes cyanosis, not pallor.

A. Elevated blood pressure B. Increased urine output C. Joint pain D. Vaginal discharge

Correct Answer is A

Explanation

Choice A reason: Elevated blood pressure is a hallmark sign of preeclampsia, which is a hypertensive disorder of pregnancy that can cause serious complications, such as eclampsia, HELLP syndrome, or placental abruption. The nurse should monitor the client's blood pressure regularly and report any readings above 140/90 mm Hg to the provider.

Choice B reason: Increased urine output is not a sign of preeclampsia, but rather a normal physiological change of pregnancy, as the renal blood flow and glomerular filtration rate increase. A client with preeclampsia may have decreased urine output, which can indicate renal impairment or oligohydramnios.

Choice C reason: Joint pain is not a sign of preeclampsia, but rather a common discomfort of pregnancy, as the hormones relaxin and progesterone loosen the ligaments and joints. A client with preeclampsia may have epigastric pain, which can indicate liver involvement or impending eclampsia.

Choice D reason: Vaginal discharge is not a sign of preeclampsia, but rather a normal occurrence of pregnancy, as the cervical glands secrete more mucus to protect the uterus from infection. A client with preeclampsia may have vaginal bleeding, which can indicate placental abruption or disseminated intravascular coagulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer is A

Explanation

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