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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:
Stimulating the infant to cry is an important action as it helps ensure that the baby's lungs are clear of fluid and are functioning properly. However, this is not the first action to take. The initial cry will often occur naturally as part of the transition from intrauterine to extrauterine life.

Choice B reason:
Clearing the respiratory tract is the priority action. Immediately after birth, it is crucial to ensure that the newborn's airway is clear to facilitate breathing. The nurse may suction the mouth and nose to remove any amniotic fluid, mucus, or other obstructions that could impede breathing.

Choice C reason:
Drying the infant off and covering the head is important to prevent heat loss, which newborns are particularly susceptible to due to their large surface area relative to body mass. However, this follows the clearance of the airway, as maintaining an open airway is the most critical initial step in newborn care.

Choice D reason:
Cutting the umbilical cord is a necessary step in the delivery process, but it is not the first action to take when caring for the newborn. The timing of cord clamping can vary, and immediate care focuses on ensuring the newborn's ability to breathe effectively.

A. "You should try to pant as the delivery proceeds." B. "You should try to perform slow-paced breathing." C. "You should go ahead and push to assist the delivery." D. "You should take a deep, cleansing breath and breathe naturally."

Correct Answer is A

Explanation

Choice a reason:
Panting can help control the urge to push and is often recommended during the crowning stage to prevent tearing and to allow the perineum to stretch gradually. It can also help manage the pain and provide the baby with a gentle descent.

Choice b reason:
Slow-paced breathing is generally advised during the earlier stages of labor to help manage contractions and maintain relaxation. However, during the crowning stage, slow-paced breathing might not be effective in controlling the strong urge to push.

Choice c reason:
Telling the client to go ahead and push without proper guidance could lead to rapid delivery, which increases the risk of perineal tearing. The nurse should instruct the client on when and how to push effectively, often during a contraction, with controlled effort.

Choice d reason:
Taking a deep, cleansing breath can be calming and help the client focus, but it does not directly address the immediate need to control the pushing during crowning. Controlled breathing techniques specific to the delivery stage are more appropriate.

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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?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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