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.

Answer and Explanation

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.

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Correct Answer is ["C","G","H"]

Explanation

A. Peripheral edema 2+ bilateral lower extremities - Peripheral edema is common postpartum and does not typically require immediate follow-up unless it is associated with other concerning signs or symptoms.
B. Blood pressure 136/6 mm Hg - The blood pressure provided appears to be incorrect, as the diastolic pressure is unusually low. However, given the options provided, blood pressure is not explicitly mentioned in the scenario as a critical factor requiring immediate follow-up.
C. Lateral deviation of the uterus - Lateral deviation of the uterus suggests uterine atony, a potential complication of postpartum hemorrhage, requiring immediate follow-up and intervention to prevent further complications.
D. Pain rating of 3 on a scale of 0 to 10 - While increased pain should be addressed, it does not necessarily indicate an emergency situation requiring immediate follow-up compared to other findings such as uterine deviation or excessive bleeding.
E. Deep tendon reflexes 1+ - This finding is within normal limits and does not require immediate follow-up.
F. Breasts soft - Soft breasts are expected in the postpartum period and do not typically require immediate follow-up unless associated with other concerning signs or symptoms.

G. Large amount of lochia rubra - A large amount of bright red lochia could indicate postpartum hemorrhage, necessitating immediate follow-up and intervention to prevent further complications.
H. Uterine tone soft - Soft uterine tone suggests uterine atony, which is a potential complication requiring immediate follow-up and intervention to prevent excessive bleeding.

A. Polyuria B. Bilateral crackles C. Hyperglycemia D. Hypotension

Correct Answer is D

Explanation

Rationale:

A. Polyuria is not a common adverse effect of opioid analgesics administered via epidural block.

B. Bilateral crackles are not typically associated with opioid analgesics administered via epidural block.

C. Hyperglycemia (high blood sugar levels) is not a common adverse effect of opioid analgesics administered via epidural block.

D. Hypotension is a common adverse effect of opioid analgesics administered via epidural block. Opioids can cause peripheral vasodilation and decreased systemic vascular resistance, leading to a drop in blood pressure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a postpartum client who delivered vaginally 8 hr ago. Exhibits Select the 3 findings that require immediate follow-up.

Correct Answer is ["C","G","H"]

Explanation

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Correct Answer is D

Explanation

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