A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather 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°.

Administer oxytocin by continuous IV infusion.

Insert an indwelling urinary catheter.

Massage the client's fundus to promote contractions.

Answer and Explanation

The Correct Answer is D

A. Tilting the client onto her right side with her legs elevated does not directly address the underlying cause of postpartum hemorrhage.
B. Oxytocin is a uterotonic medication commonly used to help control and prevent PPH by promoting uterine contractions, which can help to compress blood vessels and reduce bleeding. However, it is not the priority action.
C. Inserting an indwelling urinary catheter may be necessary to monitor urine output and empty the bladder but is not a priority.
D. Massaging the client's fundus to promote contractions is a standard intervention and initial action for managing PPH

Nursing Test Bank

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Correct Answer is B

Explanation

The symptoms describe indicate the presence of DVT which is a serious complication associated with childbirth. In addition to advising the client to see her provider immediately, the nurse should suggest interventions such as limb elevate to promote venous return and minimize discomfort.

A. Massaging the affected area can dislodge the blood clot and lead to a pulmonary embolism.

C. Cold compresses may help reduce pain and inflammation, but they do not address the underlying issue of a potential DVT.
D. Flexing the knee while resting can help improve blood flow in the affected leg and prevent stagnation but does not address the issue.

A. "If you want me to, I can tell your parents for you." B. "You seem scared to talk to your parents." C. "Your parents will have to be told why you are being admitted." D. "Give your parents a chance; they'll understand."

Correct Answer is B

Explanation

A. This response does not respect the client's autonomy and right to confidentiality.

B. This response acknowledges the client's feelings and opens up the opportunity for further discussion.
C. While it's important for parents to be informed about their child's health condition, especially if the adolescent is a minor, this response may escalate the client's anxiety and fear about disclosing their infection to their parents.
D. This response minimizes the client's concerns and may not accurately reflect the complexity of their situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A nurse is admitting an 8-hour old, term newborn following a cesarean birth. The nurse observes that the newborn's skin is yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?