A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding.
Which of the following actions should the nurse take?
Avoid performing sterile vaginal examinations
Administer betamethasone IM
Obtain a specimen for a Kleihauer-Betke test
Anticipate a prescription for misoprostol
The Correct Answer is D
Choice A rationale
Avoiding performing sterile vaginal examinations does not directly address the issue of uterine atony and excessive bleeding. While limiting vaginal examinations can reduce the risk of infection, it does not treat uterine atony.
Choice B rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication that is often given to pregnant women who are at risk of preterm birth to help mature the baby’s lungs. It does not treat uterine atony or excessive bleeding.
Choice C rationale
Obtaining a specimen for a Kleihauer-Betke test is not the appropriate action in this situation. The Kleihauer-Betke test is used to detect fetal blood in maternal circulation, which is not relevant in this case.
Choice D rationale
Anticipating a prescription for misoprostol is the correct action. Misoprostol is a medication that can be used to treat uterine atony by causing the uterus to contract, which can help control postpartum bleeding.
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Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Vacuum-assisted delivery is indeed a risk factor for postpartum hemorrhage. This method of delivery can cause trauma to the birth canal, which can lead to increased bleeding after delivery.
Choice B rationale
A history of human papillomavirus (HPV) is not typically associated with an increased risk of postpartum hemorrhage.
Choice C rationale
The newborn’s weight, whether high or low, is not typically considered a risk factor for postpartum hemorrhage.
Choice D rationale
Labor induction with oxytocin is a risk factor for postpartum hemorrhage. Oxytocin is a drug that can cause the uterus to contract too much, leading to uterine atony (a condition where the uterus doesn’t contract properly after birth), which can result in postpartum hemorrhage.
Correct Answer is B, A, C, D, E
Explanation
Step 1 is to apply a warm cloth to the newborn’s heel for 5 to 10 minutes. Warming the heel improves blood flow to the area, making it easier to obtain a blood sample.
Step 2 is to clean the area with an antiseptic. This is to prevent infection.
Step 3 is to puncture the outer aspect of the newborn’s heel. The outer aspect of the heel is less sensitive and less likely to be injured by the lancet.
Step 4 is to collect the blood specimen. After the heel has been punctured, blood will start to flow out and can be collected.
Step 5 is to apply pressure to the site with a dry gauze pad. This is to stop the bleeding after the blood sample has been collected.
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