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
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.
Correct Answer is D
Explanation
Choice A rationale
Frequent urination is a common symptom in early pregnancy due to increased blood flow to the woman’s kidneys. While it can be inconvenient, it is usually not a sign of a serious problem.
Choice B rationale
Periodic tingling of the fingers can be a symptom of carpal tunnel syndrome, which is common during pregnancy due to fluid retention causing pressure on the median nerve. While it can be uncomfortable, it is usually not a serious concern.
Choice C rationale
Back pain following intercourse can be a normal symptom of pregnancy due to hormonal changes and stretching of ligaments. It is usually not a cause for immediate concern.
Choice D rationale
Severe vomiting in early pregnancy could be a sign of hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy that can lead to dehydration and weight loss. This is a potentially serious condition that requires immediate medical attention.
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