A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

Pain Level

Amount of vaginal bleeding

Amount of urinary output

Fundal Height

Answer and Explanation

The Correct Answer is B

A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.

B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.

C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.

D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.

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Correct Answer is B

Explanation

A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.

B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.

C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.

D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.

A. Select a quiet location to talk to the client while remaining visible to staff members. B. Give the client several clear options. C. Observe the client and the situation. D. Respect the client's personal space.

Correct Answer is C

Explanation

A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment.

B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response.

C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps.

D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.

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A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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