A nurse is caring for a client who is 2 hours postpartum.
The nurse notes that the client soaked a perineal pad in 10 minutes, the client’s skin color is ashen, and she states she feels weak and light-headed.
After applying oxygen via a non-rebreather face mask at 10 L/min, which of the following actions should the nurse take next?
Tilt the client onto her right side with her legs elevated to at least 30 degrees.
Administer oxytocin by continuous IV infusion.
Insert an indwelling urinary catheter.
Massage the client’s fundus to promote contractions.
The Correct Answer is D
Choice A rationale
Tilt the client onto her right side with her legs elevated to at least 30 degrees. This action is not the most immediate step to take. While it can help improve venous return and thus cardiac output, it does not directly address the issue of postpartum hemorrhage.
Choice B rationale
Administer oxytocin by continuous IV infusion. Oxytocin is a medication that can stimulate uterine contractions and help control postpartum bleeding. However, it should be administered after the nurse has assessed the uterus and determined that it is not contracting effectively on its own.
Choice C rationale
Insert an indwelling urinary catheter. While a full bladder can inhibit effective uterine contractions and contribute to bleeding, inserting a catheter is not the first step in managing a postpartum hemorrhage.
Choice D rationale
Massage the client’s fundus to promote contractions. This is the correct answer. Fundal massage stimulates the uterus to contract, which can help control postpartum bleeding. It is a first-line intervention for a boggy uterus and postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Physiologic jaundice is a common condition in newborns, usually appearing between the second and fourth day of life. It is caused by an increase in bilirubin, a substance produced by the breakdown of red blood cells.
Choice B rationale
Maternal/newborn blood group incompatibility can cause jaundice, but it typically appears within the first 24 hours of life.
Choice C rationale
Maternal cocaine abuse can lead to various complications in the newborn, but it does not directly cause jaundice.
Choice D rationale
Absence of vitamin K does not cause jaundice. Vitamin K is given to newborns to prevent bleeding disorders.
Correct Answer is D
Explanation
Choice A rationale
Hemoglobin is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice B rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. While it is an important parameter to monitor in newborns, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice C rationale
Serum glucose is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
Choice D rationale
A respiratory assessment is crucial for a newborn, especially one that has undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non- reassuring fetal heart rate. The newborn’s Apgar score was 5 at 1 min, which indicates significant distress, and positive pressure ventilation was given for 1 min followed by free flow oxygen. These factors make respiratory assessment a priority and one of the immediate findings that the nurse should report to the provider.
Choice E rationale
Temperature is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.
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