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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 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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:

Shellfish allergies are not a contraindication to receiving the influenza vaccine. The vaccine contains no shellfish-derived ingredients.

Choice B rationale:

Egg allergies are a contraindication to receiving the influenza vaccine. Traditionally, most influenza vaccines are prepared using eggs and can provoke allergic reactions in individuals allergic to eggs. However, individuals with a mild egg allergy can often receive the vaccine under medical supervision. It is crucial to assess the severity of the egg allergy and consult with an allergist or immunologist before administering the vaccine.

Choice C rationale:

Gelatin allergies are generally not a contraindication to receiving the influenza vaccine. While some vaccines contain gelatin, it is not a component of all influenza vaccines. If the specific vaccine being administered contains gelatin, it should be avoided in individuals with a gelatin allergy.

Choice D rationale:

Milk allergies are not a contraindication to receiving the influenza vaccine. Milk or dairy products are not typically included in the influenza vaccine formulation.

A. "We can expect the hospice nurse to provide support for us after our mother's death." B. "A hospice nurse will come to the house each time our mother needs pain medication." C. "Now that my mother is receiving hospice services, we will not be able to get respite care." D. "Hospice care focuses on arranging treatment that will prolong our mother's life."

Correct Answer is A

Explanation

- A. "We can expect the hospice nurse to provide support for us after our mother's death." This statement indicates that the family understands that hospice care includes bereavement services for up to one year after the death of a loved one.

- B. "A hospice nurse will come to the house each time our mother needs pain medication." This statement indicates that the family does not understand that hospice care involves teaching them how to administer pain medication and other comfort measures to their mother at home.

- C. "Now that my mother is receiving hospice services, we will not be able to get respite care." This statement indicates that the family does not understand that hospice care offers respite care, which allows them to take a break from caregiving for a short period of time.

- D. "Hospice care focuses on arranging treatment that will prolong our mother's life." This statement indicates that the family does not understand that hospice care focuses on providing palliative care, which aims to relieve pain and suffering, rather than curative treatment, which aims to extend life.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for allergies prior to administering the influenza vaccine.The nurse should identify that an allergy to which of the following foods is a contraindication to receiving this vaccine?

Correct Answer is B

Explanation

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

Correct Answer is A

Explanation

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

A nurse is teaching about safe handling of formula to a client who is postpartum and chooses to bottle feed her newborn.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

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