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":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"}}
Explanation
Blood pressure 80/50 mm Hg: Indication of Potential Worsening Condition - A decrease in blood pressure may indicate hypovolemic shock due to ongoing or worsening postpartum hemorrhage.
Cloudy urine: Indication of Potential Worsening Condition - Cloudy urine may indicate a urinary tract infection or another complication, which can worsen the client's condition.
Moderate lochia rubra: Indication of Potential Worsening Condition - Continued moderate lochia rubra suggests ongoing or worsening postpartum hemorrhage.
Fundus firm to palpation: Indication of Potential Improvement - A firm fundus suggests effective uterine contraction and control of bleeding, indicating potential improvement.
Fundus at level of umbilicus: Indication of Potential Worsening Condition - The fundus being at the level of the umbilicus suggests uterine atony or continued bleeding, which is a worsening condition.
Correct Answer is A
Explanation
A.
Rationale:
A. Breast tenderness:
Correct answer. Clomiphene citrate, a medication used to induce ovulation, can cause breast tenderness as a common adverse effect due to its estrogenic effects.
B. Chills: Chills are not a common adverse effect of clomiphene citrate.
C. Tinnitus: Tinnitus, or ringing in the ears, is not typically associated with clomiphene citrate use.
D. Urinary frequency: Urinary frequency is not a common adverse effect of clomiphene citrate.
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