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 D

Explanation

Choice a reason:
The pattern of contractions can be a sign of true labor when they are regular, frequent, and increase in intensity and duration over time. In true labor, contractions do not subside with rest or hydration and become progressively more organized. However, contractions alone can be misleading, as Braxton Hicks contractions may also present a pattern but do not lead to cervical changes.

Choice b reason:
The station of the presenting part refers to the position of the baby's head (or presenting part) in relation to the ischial spines of the mother's pelvis. While the station can indicate how far labor has progressed, it is not a definitive sign of true labor. The station changes as labor progresses, but it can also be affected by other factors such as the baby's position.

Choice c reason:
Rupture of the membranes, commonly known as water breaking, can occur before or during labor. While it is a sign that labor may be imminent, it does not confirm true labor. Some women may experience premature rupture of membranes without contractions or cervical changes.

Choice d reason:
Changes in the cervix, including effacement (thinning) and dilation (opening), are the most reliable signs of true labor. Effacement is measured in percentages, and dilation is measured in centimeters. The cervix must be 100% effaced and dilated to 10 centimeters for childbirth to occur. These changes are a direct result of true labor contractions and indicate that the body is preparing for delivery.

A. "Exposure to rubella will suppress the newborn's immune response." B. "The child might develop encephalitis, a complication of rubella." C. "The newborn is at risk for developing a TORCH infection." D. "The newborn might be actively shedding the virus."

Correct Answer is D

Explanation

Choice A reason:
The statement that exposure to rubella will suppress the newborn's immune response is not entirely accurate. While rubella can affect the immune system, the primary concern with newborns is the risk of congenital rubella syndrome (CRS), which can cause a variety of health problems, including developmental delays and organ damage. The newborn's immune system is not fully developed, and while rubella can lead to immunosuppression, the main reason for isolation is to prevent the spread of the virus.

Choice B reason:
Encephalitis is an inflammation of the brain that can be caused by various infections, including rubella. However, it is not the most common complication associated with congenital rubella. The primary concerns with CRS are hearing loss, heart defects, and ocular issues, such as cataracts. While encephalitis is a serious condition, the immediate reason for isolation is to prevent the transmission of the virus, not specifically because of the risk of encephalitis.

Choice C reason:
TORCH infections refer to a group of infections that can cause serious health problems in newborns. The acronym stands for Toxoplasmosis, Other (such as syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus. While it is true that the newborn is at risk for developing CRS, which is part of the TORCH group, the term "TORCH infection" is a broader category and does not specifically explain why the newborn is being isolated.

Choice D reason:
The most appropriate response is that the newborn might be actively shedding the virus. Newborns with congenital rubella can shed the virus for an extended period after birth. This means they can potentially spread the virus to others, which is why isolation is necessary. Isolation helps protect other newborns, pregnant women, and immunocompromised individuals from contracting rubella, which can have serious consequences.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is D

Explanation

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?

Correct Answer is D

Explanation

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A nurse is preparing to administer methylergonovine IM to a client who has experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?