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 A
Explanation
In the event of shoulder dystocia during the second stage of labor, the provider may instruct the nurse to perform the McRoberts maneuver. This involves assisting the client in pulling their knees toward their abdomen. This position effectively flattens the sacrum, changes the angle of the pelvic inlet, and allows more room for the baby to pass through the birth canal.
Correct Answer is B
Explanation
Choice A rationale
Dehydration could be a result of prolonged nausea and vomiting, but it is not the primary condition. Dehydration is a complication, not the cause of the symptoms.
Choice B rationale
The patient is most likely experiencing Hyperemesis Gravidarum, a severe form of nausea and vomiting in pregnancy. It’s more extreme than the typical morning sickness experienced during pregnancy and can lead to weight loss and dehydration. The nurse should ensure the patient stays hydrated and monitor their weight. Antiemetic medications may be prescribed to help control the vomiting.
Choice C rationale
Gastroenteritis typically involves both vomiting and diarrhea, often accompanied by abdominal pain and fever. The patient’s symptoms do not indicate gastroenteritis.
Choice D rationale
Food poisoning is usually associated with consuming contaminated food or water and often involves symptoms such as abdominal cramps and diarrhea, which the patient does not report.
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