A nurse is caring for a client who is postpartum and received methylergonovine (methergine). Which of the following findings indicates that the medication was effective?
Report of absent breast pain
Increase in lochia
Increase in blood pressure
Fundus firm to palpation
The Correct Answer is D
Choice A) Report of absent breast pain is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client does not have mastitis or engorgement. Mastitis is an infection of the breast tissue that causes pain, swelling, redness, and fever. Engorgement is a condition where the breasts become overfilled with milk, causing pain, hardness, and leakage. Both conditions are common in postpartum women who are breastfeeding, but they are not related to methylergonovine or uterine bleeding. Therefore, this response is irrelevant and inaccurate.
Choice B) Increase in lochia is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the medication was ineffective or that the client has a complication. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the uterus after childbirth. It usually lasts for about 4 to 6 weeks and gradually decreases in amount and color. Methylergonovine is a medication that helps to control uterine bleeding by improving the tone and contractions of the uterus. An increase in lochia may mean that methylergonovine did not work well or that the client has a problem such as retained placenta, infection, or subinvolution. Therefore, this response is opposite and inaccurate.
Choice C) Increase in blood pressure is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client has a side effect or a risk factor. Blood pressure is the force of blood against the walls of the arteries. It is measured by two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure when the heart rests). The normal range for blood pressure is 120/80 mm Hg or lower. Methylergonovine is a medication that can cause vasoconstriction, which means narrowing of the blood vessels and increasing of the blood pressure. This can lead to complications such as hypertension, stroke, or heart attack. Therefore, this response is adverse and inaccurate.
Choice D) Fundus firm to palpation is correct because this is a finding that indicates that the medication was effective and that the client has a good outcome. The fundus is the upper part of the uterus that can be felt through the abdomen after childbirth. It should be firm, midline, and at or below the level of the navel. A firm fundus means that the uterus has contracted well and stopped bleeding. Methylergonovine is a medication that helps to achieve this by improving the tone and contractions of the uterus. Therefore, this response is positive and accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) Check the baby's diaper is incorrect because this is not a priority action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Checking the baby's diaper may be part of routine care, but it does not address the underlying cause of the grunting or improve the baby's oxygenation. Therefore, this action should be done after assessing and treating the baby's respiratory status.
Choice b) Place a pacifier in the baby's mouth is incorrect because this is not an appropriate action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Placing a pacifier in the baby's mouth may interfere with the baby's breathing and worsen the grunting, as it can obstruct the airway, increase the work of breathing, or cause aspiration. Therefore, this action should be avoided or used with caution for babies who are grunting.
Choice c) Have the mother feed the baby is incorrect because this is not a safe action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Having the mother feed the baby may increase the risk of choking or aspiration, as the baby may not be able to coordinate sucking, swallowing, and breathing. Therefore, this action should be delayed or modified until the baby's respiratory status improves.
Choice d) Assess the respiratory rate is correct because this is the most important action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Assessing the respiratory rate can help to determine the severity and cause of the respiratory distress, as well as guide further interventions such as oxygen therapy, suctioning, or medication. The normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute, and it may vary with sleep or activity. A respiratory rate above 60 breaths per minute or below 30 breaths per minute indicates abnormality and requires immediate attention. Therefore, this action should be done as soon as possible for babies who are grunting.
Correct Answer is A
Explanation
Choice A) Maternal blood type is correct because this is an essential and relevant information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Spontaneous abortion, also known as miscarriage, is the loss of pregnancy before 20 weeks of gestation. It can be caused by various factors such as chromosomal abnormalities, infections, trauma, or hormonal imbalances. Maternal blood type is the classification of blood based on the presence or absence of antigens and antibodies on the red blood cells and plasma. The most common blood types are A, B, AB, and O, and each can be positive or negative for the Rh factor. Checking maternal blood type can help to identify and prevent Rh incompatibility, which is a condition that occurs when the mother has Rh-negative blood and the fetus has Rh-positive blood. This can cause the mother's immune system to produce antibodies that attack the fetal red blood cells, leading to hemolytic disease of the fetus and newborn (HDFN), which can cause anemia, jaundice, or death. To prevent this, the nurse should administer Rh immunoglobulin (RhoGAM) to the mother within 72 hours after a spontaneous abortion or any event that may cause mixing of maternal and fetal blood. Therefore, this information is vital and appropriate for the nurse to check.
Choice B) Past obstetric history is incorrect because this is not an essential or urgent information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Past obstetric history is the record of previous pregnancies and their outcomes, such as number, duration, complications, or interventions. It can provide useful information for assessing the risk factors and health status of the current pregnancy. However, it does not have any immediate impact or implication for the management of a spontaneous abortion, which is a common and unpredictable event that affects about 10% to 20% of all pregnancies. Therefore, this information can be obtained later or from other sources by the nurse.
Choice C) Maternal varicella titer is incorrect because this is not a relevant or necessary information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Varicella titer is a blood test that measures the level of antibodies against varicella-zoster virus (VZV), which causes chickenpox and shingles. It can indicate whether a person has immunity to VZV or needs vaccination. Checking maternal varicella titer may be important for pregnant women who have not had chickenpox or vaccination before, as VZV infection during pregnancy can cause congenital varicella syndrome (CVS), which can affect the development and function of various organs in the fetus. However, it does not relate to spontaneous abortion, which is not caused by VZV infection or immunity. Therefore, this information is irrelevant and unnecessary for the nurse to check.
Choice D) Cervical patency is incorrect because this is not a reliable or accurate information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Cervical patency means how open or closed the cervix is, which can affect the progress and outcome of labor and delivery. The cervix is usually closed and firm during pregnancy, but it gradually softens, shortens, and dilates as labor approaches. Checking cervical patency can help to determine if labor has started or if there are any complications such as preterm labor or cervical incompetence.
However, it does not indicate if a spontaneous abortion has occurred or not, as the cervix may remain closed or partially open after a miscarriage. Moreover, checking cervical patency can be invasive and uncomfortable for the woman who has had a spontaneous abortion, and it may increase the risk of infection or bleeding. Therefore, this information should be checked only when indicated by the physician and with caution by the nurse.
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