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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A score of 9 on the Edinburgh Postnatal Depression Screen (EPDS) on postpartum day 2 is below the clinical cutoff score of 10, which is used to distinguish health controls versus possible depression. Therefore, this score would not indicate a high risk of developing a depressive disorder.
Choice B rationale
A score of 11 on the EPDS on postpartum day 30 is above the clinical cutoff score of 1034. This score indicates a high risk of developing a depressive disorder. Therefore, further assessment and possible intervention would be necessary.
Choice C rationale
While discharge teaching is an important aspect of postpartum care, it does not provide information about the client’s risk of developing postpartum depression. Therefore, this choice does not answer the question.
Choice D rationale
A follow-up appointment with a provider in 4 weeks is a standard part of postpartum care, but it does not provide information about the client’s risk of developing postpartum depression.
Therefore, this choice does not answer the question.
Correct Answer is C
Explanation
Choice A rationale
Contractions feeling further apart is not a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice B rationale
Feeling relief from pelvic pressure may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice C rationale
Improvement in back labor is a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice D rationale
Lessening of suprapubic pain may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
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