A nurse is caring for a client with postpartum hemorrhage.
The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

Assess the client’s pain scale.

Assess the client’s respiratory rate.

Assess the client’s blood pressure.

Assess the client’s last bowel movement.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Assess the client’s blood pressure. Methylergonovine is a uterotonic medication that can cause hypertension and is contraindicated for clients with preeclampsia or cardiac disease.

Therefore, the nurse should check the client’s blood pressure before administering this medication to ensure it is within normal range (120/80 mm Hg or lower).

Choice A is wrong because assessing the client’s pain scale is not a priority assessment before giving methylergonovine.

Pain is not a contraindication for this medication and does not affect its effectiveness.

Choice B is wrong because assessing the client’s respiratory rate is not a priority assessment before giving methylergonovine.

Respiratory rate is not affected by this medication and does not indicate any adverse effects.

Choice D is wrong because assessing the client’s last bowel movement is not a priority assessment before giving methylergonovine.

Bowel movement is not related to postpartum hemorrhage or uterine atony, which are the indications for this medication.

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Correct Answer is D

Explanation

The correct answer is choice D. Placing warmed tea bags on the nipples is not a recommended method to avoid nipple soreness while breastfeeding.Tea bags can cause dryness and cracking of the nipples, which can increase the risk of infection and pain.

Choice A is wrong because it is better to use both breasts at each feeding and switch the starting breast at each feeding.This helps to ensure adequate milk production and drainage.

Choice B is correct because rubbing breast milk into the nipple can help to moisturize and protect the nipple from infection.Breast milk has antibacterial and healing properties.

Choice C is correct because washing the nipples with water but no soap can help to prevent irritation and dryness of the nipples.

Soap can remove the natural oils that protect the skin.Letting the nipples air dry can also help to prevent fungal growth.

A. Document urine output hourly. B. Avoid sexual intercourse. C. Maintain a darkened, quiet environment. D. Eat small, frequent meals.

Correct Answer is B

Explanation

The correct answer is choice B. The client should avoid sexual intercourse.Sexual intercourse may stimulate uterine contractions and increase the risk of preterm labor.The client should also avoid activities that may cause dehydration, infection, or stress.

Choice A is wrong because documenting urine output hourly is not necessary for a client with preterm labor who is discharged home.Urine output may be affected by hydration status, kidney function, or medication use, but it is not a reliable indicator of preterm labor.

Choice C is wrong because maintaining a darkened, quiet environment is not required for a client with preterm labor who is discharged home.The client may benefit from rest and relaxation, but there is no evidence that light or noise affects preterm labor.

Choice D is wrong because eating small, frequent meals is not specific to a client with preterm labor who is discharged home.Eating small, frequent meals may help with nausea, heartburn, or blood sugar control, but it does not prevent preterm labor.

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A nurse is caring for a client with postpartum hemorrhage. The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

Nursing Test Bank

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A nurse is caring for a client with postpartum hemorrhage.
The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?