A nurse is caring for a client who is 2 hours postpartum.
The client has an IV infusion of lactated Ringer’s with 25 units of oxytocin and large lochia rubra.
Vital signs include blood pressure 146/81, pulse 80/min, and respirations 18/min.
Which of the following actions should the nurse clarify with the provider?

Administer oxygen by non-rebreather mask at 5 L/min.

Administer methylergonovine 0.2 mg IM now.

Insert a urinary catheter.

Increase the infusion rate of the IV fluid.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Oxygen administration is not indicated in this situation. The client's vital signs are stable, and there is no evidence of

respiratory distress.

Oxygen administration could potentially mask signs of postpartum hemorrhage, which is a serious complication.

It is important to assess the client's respiratory status closely, but oxygen should not be administered unless there is a clear

indication for it.

Choice B rationale:

Methylergonovine is a medication that is used to treat postpartum hemorrhage.

It works by contracting the uterus and reducing blood flow.

However, it is a potent medication that can have serious side effects, such as hypertension and seizures.

It is important to clarify the order with the provider before administering this medication.

The provider may want to assess the client further or consider other options before ordering methylergonovine.

Choice C rationale:

Inserting a urinary catheter is not necessary in this situation.

The client is not experiencing any urinary problems, and there is no evidence of bladder distention.

Catheterization can increase the risk of urinary tract infection, so it should only be performed when there is a clear indication

for it.

Choice D rationale:

Increasing the infusion rate of the IV fluid may be helpful in some cases of postpartum hemorrhage.

However, it is important to assess the client's fluid status before increasing the infusion rate.

Too much fluid can lead to pulmonary edema, which is a serious complication.

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Correct Answer is A

Explanation

Choice A rationale:

Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor

due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.

Key signs of umbilical cord compression include:

Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They

are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.

Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be

a sign of cord compression, as the compression can impair placental blood flow.

Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,

including cord compression.

Immediate action is crucial when umbilical cord compression is suspected. The nurse should:

Notify the provider immediately.

Change the mother's position: This can help relieve pressure on the cord. Common positions include:

Lateral positioning (lying on the side)

Trendelenburg position (lying on the back with the head tilted down)

Knee-chest position (kneeling with the chest on the bed)

Administer oxygen to the mother: This can increase fetal oxygenation.

Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid

volume), internal fetal monitoring, or cesarean delivery.

Choice B rationale:

Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not

require intervention unless it causes significant changes in the FHR or other signs of fetal distress.

Choice C rationale:

Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are

significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report

any concerns to the provider.

Choice D rationale:

Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that

occur after the peak of a contraction is "late decelerations."

A. Swelling in both breasts. B. Cracked and bleeding nipples. C. Red and painful area in one breast. D. Increase in breast milk production.

Correct Answer is C

Explanation

Choice A rationale:

Swelling in both breasts is a common finding in breastfeeding women, especially in the early postpartum period. It is often due

to engorgement, which is caused by an oversupply of milk and/or infrequent milk removal.

While engorgement can sometimes lead to mastitis, it is not a definitive sign of the condition.

Other causes of bilateral breast swelling, such as milk stasis or plugged ducts, should also be considered.

Choice B rationale:

Cracked and bleeding nipples can be a symptom of mastitis, but they are not always present.

They can also be caused by other factors, such as improper latch, thrush, or dry skin.

It is important to assess for other signs and symptoms of mastitis, such as fever, chills, and breast tenderness, to make a

definitive diagnosis.

Choice C rationale:

A red and painful area in one breast is a classic sign of mastitis.

This is typically caused by inflammation of the breast tissue, often due to a bacterial infection.

The redness and pain are usually localized to the affected area, and may be accompanied by warmth, swelling, and firmness.

Choice D rationale:

An increase in breast milk production is not a sign of mastitis.

In fact, it is often a sign that breastfeeding is going well.

However, if the milk is not being removed effectively, it can lead to engorgement and blocked ducts, which can increase the

risk of mastitis.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the monitoring of a client who is in labor. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and is breastfeeding her infant. Which of the following findings indicates mastitis?

Correct Answer is C

Explanation

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia.Which of the following responses should the nurse make?

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min.Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who is in the second stage of labor.The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which of the following actions should the nurse take?

A nurse is performing an assessment on a postpartum patient. The uterus is found to be displaced to the right.Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is at 7 cm of cervical dilation and 100% effacement, and in active labor.The client informs the nurse that she needs to push.Which of the following is the appropriate action for the nurse to take?

A nurse is preparing to administer dinoprostone gel to a client who is pregnant. The client asks the nurse about the purpose of the medication.Which of the following responses should the nurse make?

A nurse is assisting in the care of a client who is at 38 weeks of gestation. What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?