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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
1. Potential Condition:
- Hypoglycemia: The newborn is jittery and has decreased muscle tone, which are common signs of hypoglycemia (low blood sugar), especially in a newborn large for gestational age.
2. Actions to Take:
- Check the newborn's capillary blood glucose level: This is crucial to confirm if hypoglycemia is the issue and to determine the appropriate treatment.
- Place the newborn under a radiant warmer: This action helps stabilize the newborn’s body temperature, which is important as hypoglycemia can sometimes be associated with temperature instability.
3. Parameters to Monitor:
- Temperature: Monitoring the temperature is important to ensure the newborn maintains normal body temperature and to identify any possible hypothermia.
- Seizure activity: Jitteriness can sometimes progress to seizures if hypoglycemia is severe, so monitoring for seizure activity is critical.
Correct Answer is A
Explanation
Inserting a gloved hand into the vagina to relieve pressure on the cord. This helps to prevent compression and compromise of blood flow to the fetus.
The other cations can follow the relief of pressure i.e B, D, C
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.