A nurse is caring for a client who is 1 hr 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.
Anticipate a prescription for misoprostol.
Obtain a specimen for a Kleihauer-Betke test.
Administer betamethasone IM.
The Correct Answer is B
Rationale:
A. Avoiding sterile vaginal examinations is not the appropriate action for managing uterine atony and postpartum hemorrhage. Vaginal examinations may be necessary to assess the degree of cervical dilation and to identify potential causes of bleeding.
B. Anticipating a prescription for misoprostol is appropriate for managing uterine atony and postpartum hemorrhage. Misoprostol is a prostaglandin analog that helps to promote uterine contractions and control bleeding.
C. Obtaining a specimen for a Kleihauer-Betke test is not the priority action in this situation. The Kleihauer-Betke test is used to estimate the amount of fetal-maternal hemorrhage in Rh-negative mothers.
D. Administering betamethasone IM is not indicated for the management of uterine atony and postpartum hemorrhage. Betamethasone is a corticosteroid used to promote fetal lung maturity when preterm birth is anticipated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F","G"]
Explanation
Rationale:
A. Newborns with neonatal abstinence syndrome (NAS) are often irritable and hypersensitive to stimuli. Keeping the environment calm and quiet can help minimize their discomfort.
B. Naloxone is not routinely used in the management of NAS unless there is evidence of severe respiratory depression or opioid overdose, which is not indicated in this scenario.
C. Maternal opioid use and positive urine drug screens for methadone may contraindicate breastfeeding due to the potential transmission of opioids to the infant through breast milk. It's essential to consult with healthcare providers regarding the safest feeding option for the newborn.
D. Eye contact during feeding is essential for bonding between the parent and the newborn and should not be discouraged unless medically necessary.
E. Ballard newborn screening helps assess the newborn's gestational age and guide appropriate care for neonates with NAS, as they may require specialized management.
F. Daily weighing helps monitor the newborn's hydration status and overall well-being, which is crucial in managing NAS and ensuring adequate nutrition.
G. Swaddling can provide comfort to newborns with NAS by mimicking the womb environment and reducing their agitation.
Correct Answer is A
Explanation
A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.
B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.
C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.
D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.
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