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A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes

1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

Firmly massage the uterine fundus.

Provide emotional support.

Administer oxygen.

Weigh the perineal pads.

Insert indwelling urinary catheter.

Administer methylergonovine.

Administer terbutaline.

Answer and Explanation

Correct Answer : A,B,C,D,E,F

A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.

B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.

C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss.

D: Correct. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.

E: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively.

F: Correct. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.

G: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.

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Correct Answer is C

Explanation

A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.

B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.

C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.

D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.

A. Perform gastrostomy feedings through a client's established gastrostomy tube. B. Determine if the PRN pain medication administered 30 min ago has helped. C. Provide instructions about client care to a family member over the telephone. D. Teach a client how to measure their own blood pressure.

Correct Answer is B

Explanation

A. Incorrect. Performing gastrostomy feedings is a complex task that requires specialized training and assessment skills. The nurse should not delegate this task to an AP who has not received the appropriate education and competency validation.

B. Correct. Determining if the PRN pain medication has helped is a simple task that involves asking the client about their pain level and documenting the response. The nurse can delegate this task to an AP as long as they follow up with the client and evaluate the effectiveness of the pain management plan.

C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.

D. Incorrect. Teaching a client how to measure their own blood pressure is a task that requires teaching and evaluation skills. The nurse should not delegate this task to an AP who might not be able to explain the procedure, demonstrate the technique, or assess the client's learning.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is B

Explanation

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