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

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Correct Answer is D

Explanation

Drying the newborn's skin helps prevent heat loss through evaporation, which is crucial for maintaining the newborn's body temperature and preventing hypothermia. Administering vitamin K, eye prophylaxis, and placing an identification bracelet are important aspects of newborn care but not priority.

A. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding B. A client who has missed a period and reports vaginal spotting C. A client who is at 14 weeks of gestation and reports nausea and vomiting D. A client who is at 38 weeks of gestation and reports a cough and fever

Correct Answer is A

Explanation

Painless vaginal bleeding in the third trimester could be a sign of placenta previa or placental abruption, both of which are serious conditions requiring immediate medical attention. This client should be seen first due to the potential urgency of the situation.
B. Vaginal spotting in early pregnancy may indicate implantation bleeding or other benign causes, but it could also be a sign of threatened miscarriage or ectopic pregnancy. While this client needs assessment, it's not as urgent as antepartum hemorrhage.
C. A client who is at 14 weeks of gestation and reports nausea and vomiting:

Nausea and vomiting are common symptoms in early pregnancy and typically do not require urgent intervention unless severe dehydration or hyperemesis gravidarum is present.
D. A cough and fever in late pregnancy may indicate a respiratory infection or another illness, but it does not pose an immediate threat to maternal or fetal health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Correct Answer is D

Explanation

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

Correct Answer is A

Explanation

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 preparing to administer methylergonovine IM to a client who 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 is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

A nurse receives a mother and baby in postpartum. The baby is approximately 2 hours old. During the assessment of the baby the nurse recognizes the following symptoms of transient tachypnea of the newborn except for-

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?