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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason:

"I will avoid using my microwave oven at home because of the ICD."This statement is incorrect. Using a microwave oven does not interfere with the functioning of an ICD. It is safe for clients with ICDs to use microwave ovens.

Choice B reason:

"I can hold my cell phone on the same side of my body as the ICD."This statement is incorrect Holding a cell phone on the same side of the body as the ICD should not cause any harm or interfere with the device's functioning.

Choice C reason:

"I will wear loose clothing over my ICD." This statement is correct and demonstrates understanding of the teaching. Wearing loose clothing over the ICD helps prevent excessive pressure or friction on the device and reduces the risk of dislodging the ICD leads or causing discomfort.

Choice D reason:

"I will soak in the tub rather than showering." This statement is incorrect. Avoiding showers is not necessary for clients with ICDs. Taking showers is generally safe for individuals with ICDs, as the device is designed to be waterproof and withstand such conditions.

A. Insert air in the tube and listen for gurgling sounds in the epigastric area. B. Aspirate contents from the tube and verify the pH level. C. Review the medical record for previous x-ray verification of placement. D. Auscultate the lungs for adventitious breath sounds.

Correct Answer is B

Explanation

A. This is an incorrect action. Inserting air in the tube and listening for gurgling sounds in the epigastric area is not a reliable method to confirm NG tube placement, as it can produce false-positive results due to air entering the stomach or intestines.

B. This is a correct action. Aspirating contents from the tube and verifying the pH level is a valid method to confirm NG tube placement, as gastric contents typically have a pH of less than 5.5, while intestinal or respiratory contents have a higher pH.

C. This is an incorrect action. Reviewing the medical record for previous x-ray verification of placement is not sufficient to confirm NG tube placement, as the tube can migrate or become dislodged after insertion. X-ray verification should be done initially and whenever there is doubt about the tube's position.

D. This is an incorrect action. Auscultating the lungs for adventitious breath sounds is not a specific method to confirm NG tube placement, as it can indicate other conditions such as pneumonia or pulmonary edema. It can also miss signs of respiratory complications due to NG tube misplacement, such as pneumothorax or bronchial obstruction.

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