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 A
Explanation
he correct answer is choice A. “Instead of having eggs, I am eating yogurt for breakfast.” This statement shows a need for further instruction because eggs are a good source of protein and yogurt is not.
Yogurt is a dairy product that contains mostly carbohydrates and some fat.
Eggs are an animal product that contains mostly protein and some fat.
Protein is important for building and repairing tissues in the body.
Choice B is correct because adding powdered milk to skim milk increases the protein content of the drink.
Powdered milk is a dairy product that contains protein, carbohydrates and fat.
Skim milk is a dairy product that contains protein and carbohydrates but no fat.
Choice C is correct because peanut butter is a good source of protein and healthy fats.
Peanut butter is a plant product that contains protein, fat and some carbohydrates.
Crackers are a grain product that contains mostly carbohydrates and some protein.
Choice D is correct because cream of tomato soup is a good source of protein and calories.
Cream of tomato soup is a processed food that contains tomatoes, cream, flour and seasonings.
Tomatoes are a vegetable that contains mostly water and some carbohydrates.
Cream is a dairy product that contains mostly fat and some protein.
Flour is a grain product that contains mostly carbohydrates and some protein.
Seasonings are herbs and spices that contain mostly flavor and some nutrients.
The normal range of protein intake for adults is 0.8 to 1 gram per kilogram of body weight per day.
This means that an adult who weighs 70 kilograms should consume about 56 to 70 grams of protein per day.
Correct Answer is D
Explanation
The correct answer is choice D. Encourage the client to drink cold, carbonated fluids throughout the day.This helps to relieve the shoulder pain caused by the carbon dioxide gas used to inflate the abdomen during laparoscopy.
The gas irritates the diaphragm, which refers pain to the shoulder.Drinking cold, carbonated fluids can help expel the gas and reduce the pain.
Choice A is wrong because an abdominal binder is not necessary for a laparoscopic procedure.It is more commonly used for abdominal surgeries that involve a large incision.
Choice B is wrong because a rocking chair is not helpful for a client who had a laparoscopic BTL.It is more useful for a client who had a vaginal delivery to promote comfort and uterine involution.
Choice C is wrong because keeping the head of the bed flat for six hours is not indicated for a laparoscopic BTL.It may increase the risk of venous thromboembolism and pulmonary embolism due to prolonged immobility.The client should be encouraged to ambulate as soon as possible after surgery.
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