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 lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min, which of the following actions should the nurse take next?

Insert an indwelling urinary catheter.

Administer oxytocin by continuous IV infusion.

Massage the client's fundus to promote contractions.

Tilt the client onto her right side with her legs elevated to at least 30 degrees.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Inserting an indwelling urinary catheter can be helpful in measuring urine output and reducing bladder distention, which may impede uterine contractions. However, it is not the immediate next step in managing postpartum hemorrhage.

Choice B reason:
Administering oxytocin by continuous IV infusion is a standard intervention to promote uterine contractions after delivery, which helps to control bleeding. However, before starting an oxytocin infusion, it is important to ensure that there are no retained placental fragments and that the uterus is not already well-contracted.

Choice C reason:
Massaging the client's fundus is the priority action because it can stimulate uterine contractions, which are essential for controlling postpartum bleeding. A firm, contracted uterus helps to compress the blood vessels and prevent excessive bleeding.

Choice D reason:
Tilting the client onto her right side with her legs elevated can help improve venous return and may be part of the management for shock. However, the immediate concern in a postpartum client with excessive bleeding is to manage the bleeding by promoting uterine contractions.

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Correct Answer is B

Explanation

Choice A reason:
Initiating pushing in a client with suspected placenta previa is contraindicated. Placenta previa is a condition where the placenta covers the cervix, and pushing could lead to severe bleeding and compromise both the mother and the fetus. The normal labor process involves pushing only after full cervical dilation, and in the case of placenta previa, this could exacerbate the condition.

Choice B reason:
Preparation for cesarean birth is the correct action when placenta previa is suspected. With placenta previa, vaginal delivery could cause significant hemorrhage due to the placenta's position over the cervical opening. A cesarean birth bypasses the cervix, thereby avoiding disruption of the placenta and preventing excessive bleeding.

Choice C reason:
Magnesium sulfate is used in obstetrics to prevent seizures in preeclampsia and to delay preterm labor, not for placenta previa. While it is important to manage the client's overall condition, magnesium sulfate would not address the immediate concern of potential hemorrhage due to placenta previa.

Choice D reason:
An examination to determine cervical status in the presence of placenta previa should be avoided unless absolutely necessary and performed under controlled conditions, such as in an operating room where a cesarean delivery can be performed if needed. Digital cervical examinations can dislodge the placenta and cause bleeding.

A. Diminished deep-tendon reflexes B. Respiratory rate of 16/min C. Urine output of 50 mL/hr D. Heart rate of 56/min

Correct Answer is B

Explanation

Choice A reason:
Magnesium sulfate is used in the management of severe preeclampsia primarily for seizure prophylaxis. One of the key side effects of magnesium sulfate is its impact on neuromuscular transmission, leading to diminished deep-tendon reflexes as serum magnesium levels rise. The therapeutic range for anticonvulsant prophylaxis is typically between 5-8 mg/dL. Reflexes may begin to diminish when serum levels reach 8-12 mg/dL, indicating potential magnesium toxicity. Therefore, diminished reflexes are a warning sign to reassess the infusion rate and possibly reduce or discontinue the medication.

Choice B reason:
A respiratory rate of 16 breaths per minute falls within the normal adult range and suggests that the client's respiratory system is not being adversely affected by the magnesium sulfate infusion. Respiratory rate is a critical parameter to monitor during magnesium sulfate therapy, as respiratory depression is a serious side effect of magnesium toxicity. Maintaining a normal respiratory rate indicates that it is safe to continue the infusion at the current rate.

Choice C reason:
While a urine output of 50 mL/hr is on the lower end of the normal range, it is still considered adequate for most adults. In the setting of magnesium sulfate therapy for severe preeclampsia, maintaining adequate urine output is essential for ensuring that the kidneys can excrete the magnesium to prevent accumulation and toxicity. If urine output decreases significantly, it may necessitate reevaluation of the infusion rate or additional interventions to support renal function.

Choice D reason:
A heart rate of 56 beats per minute is slightly bradycardic but may not be clinically significant if the client is asymptomatic. However, magnesium has a direct effect on cardiac function, and high levels can lead to bradycardia and other cardiac conduction abnormalities. It is important to monitor the client's heart rate and rhythm during magnesium sulfate therapy to detect any early signs of cardiac involvement due to magnesium toxicity.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

Correct Answer is B

Explanation

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Correct Answer is B

Explanation

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?