Try Naxlex NCLEX-RN (Free-Trial)

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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

- A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.

- B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.

- C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.

- D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.

A. "You will be standing with your feet 1 foot apart." B. "You will place and hold your hands on your hips." C. "I will be standing across the room from you to evaluate your sense of balance." D. "I will be checking you once with your eyes open and once with them closed."

Correct Answer is D

Explanation

A is incorrect because the client should stand with their feet together, not 1 foot apart, for the Romberg test.

B is incorrect because the client should hold their arms at their sides, not on their hips, for the Romberg test.

C is incorrect because the nurse should stand close to the client, not across the room, to prevent injury in case of a fall.

D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?

Correct Answer is B

Explanation

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A nurse is planning care for a client prior to an amniocentesis.Which of the following actions should the nurse include in the plan of care?

A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching?