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 D

Explanation

Rationale

Station refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis, which serve as a reference point during labor.

A. The mother applies lotion to the newborn's skin. B. The newborn's eyes are covered with a mask. C. The newborn's stools increase in number. D. A pink rash appears on the newborn's trunk. E. A pink rash appears on the newborn's trunk.

Correct Answer is D

Explanation

A pink rash appearing on the newborn's trunk while receiving phototherapy may indicate a potential adverse reaction to the treatment, such as a phototoxic reaction or erythema. This finding should be promptly assessed by the nurse as it may indicate skin irritation or sensitivity to the phototherapy.
A. The mother applying lotion to the newborn's skin is generally not contraindicated during phototherapy,

B. Covering the newborn's eyes with a mask is a standard practice during phototherapy to protect the eyes from exposure to the light, and it does not typically require intervention.
C. An increase in the number of newborn's stools is a common side effect of phototherapy and is not typically concerning unless accompanied by other symptoms such as diarrhea or dehydration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is D

Explanation

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?

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 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 in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?