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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B.“The placenta was blocking the opening of the womb.”
This statement shows that the patient understands that placenta previa is a condition where the placenta covers or is near the internal os of the cervix, which prevents a safe vaginal delivery.The patient would need a cesarean delivery to avoid bleeding and complications.
Choice A is wrong because it describes placental abruption, not placenta previa.
Placental abruption is when the placenta separates from the uterine wall before delivery, which can cause severe bleeding and fetal distress.
Choice C is wrong because it describes a normal position of the placenta at the top of the womb.
This does not interfere with vaginal delivery and does not cause bleeding.
Choice D is wrong because it describes placenta increta or percreta, not placenta previa.
Placenta increta or percreta is when the placenta grows too deeply into or through the uterine wall, which can cause severe bleeding and damage to the uterus and other organs.
Correct Answer is C
Explanation
This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.
Choice A: Obtain a full history is wrong because it is not the most urgent action.
A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.
Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.
Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.
Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.
Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.
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