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 and Weigh the perineal pads.
Insert indwelling urinary catheter and Administer methylergonovine.
Administer terbutaline.
Correct Answer : A,B,C,D
- 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. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.
- B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.
- C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.
- D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.
Correct Answer is B
Explanation
Use a reward system to modify the child's behavior.
Rationale:
- A. Incorrect. Maintaining a flexible daily schedule for the child may increase their anxiety and confusion, as they may have difficulty adapting to changes in routine and expectations. The nurse should advise the parents to establish a consistent and structured schedule for the child, with clear rules and boundaries.
- B. Correct. Using a reward system to modify the child's behavior is an effective strategy to reinforce positive behaviors and reduce negative ones. The nurse should help the parents identify specific and measurable goals for the child, and provide them with praise, tokens, or privileges when they achieve them.
- C. Incorrect. Providing a variety of family members to care for the child may overwhelm them and impair their social skills development, as they may have difficulty forming attachments and communicating with different people. The nurse should encourage the parents to select one or two primary caregivers for the child, who can provide them with consistent and supportive interactions.
- D. Incorrect. Administering alprazolam as needed to reduce the child's anxiety is not recommended, as it may cause adverse effects such as sedation, dependence, or withdrawal symptoms. The nurse should educate the parents about nonpharmacological interventions for anxiety, such as relaxation techniques, cognitive behavioral therapy, or social skills training.
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