A nurse is caring for a client who is postpartum and has received methylergonovine. Which of the following findings indicates that the medication was effective?
Fundus firm to palpation
Report of absent breast pain
Increase in lochia
Increase in blood pressure
The Correct Answer is A
Choice A reason:
Methylergonovine is used postpartum to prevent or control uterine bleeding by causing the uterus to contract. A firm fundus upon palpation indicates that the uterus is contracting well, which helps to compress the blood vessels and prevent excessive bleeding. This is the expected outcome when methylergonovine is effective.
Choice B reason:
The absence of breast pain is not directly related to the effectiveness of methylergonovine. Breast pain or engorgement typically occurs when milk comes in a few days postpartum and is not influenced by uterotonic medications.
Choice C reason:
An increase in lochia, or postpartum vaginal discharge, is not an indicator of methylergonovine's effectiveness. Lochia will naturally change and decrease as the postpartum period progresses and is not directly affected by the medication.
Choice D reason:
An increase in blood pressure is not an expected effect of methylergonovine and could indicate a side effect or complication. Methylergonovine can cause hypertension as a side effect, so an increase in blood pressure would warrant further assessment rather than indicating effectiveness.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Administering a prescribed oxytocic preparation is an important step in managing postpartum hemorrhage, as it helps to contract the uterus and reduce bleeding. However, it is not the first action a nurse should take when a client has saturated a perineal pad within 10 minutes postpartum.
Choice B reason:
Assessing the bladder for distention is also important because a full bladder can impede the contraction of the uterus and lead to increased bleeding. However, this is not the immediate action to take in the event of excessive postpartum bleeding.
Choice C reason:
Massaging the client's fundus is the first action the nurse should take. A boggy uterus, which is soft and not well contracted, can lead to excessive bleeding. Fundal massage stimulates the uterus to contract and can quickly reduce blood loss.
Choice D reason:
Assessing the client's blood pressure is vital to determine the client's hemodynamic status, but it is not the first action to take. The priority is to address the cause of the bleeding and stabilize the client.
Correct Answer is ["A","C","D","E"]
Explanation
Choice a reason:
Washing the perineal area using a squeeze bottle of warm water after each voiding is a recommended practice to reduce the risk of infection. This method gently cleanses without causing irritation and ensures that any bacteria are washed away, which is particularly important after a vaginal delivery when the perineal tissue may be more susceptible to infection.
Choice b reason:
Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, but it is not directly related to reducing the risk of infection. Ice packs should be used as part of pain management and swelling reduction rather than for hygiene purposes.
Choice c reason:
Blotting the perineal area dry after cleansing is important to maintain the integrity of the skin and prevent moisture buildup, which can create an environment conducive to bacterial growth. Patting the area dry gently can help prevent irritation and reduce the risk of infection.
Choice d reason:
Cleaning the perineal area from front to back is a critical practice to prevent the spread of bacteria from the anal area to the vagina and urethra, which can cause urinary tract infections. This technique is especially important postpartum when the perineal area is healing.
Choice e reason:
Performing hand hygiene before and after voiding is a fundamental practice to prevent the introduction of pathogens to the perineal area and reduce the risk of infection. Proper handwashing can significantly decrease the likelihood of perineal infections by ensuring that the hands are clean when they come into contact with sensitive areas.
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