A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Administer oxytocin.

Observe for pooling of blood under the buttocks.

Check the client's blood pressure.

Massage the client's fundus.

Answer and Explanation

The Correct Answer is D

Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.

Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

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Correct Answer is A

Explanation

Asymmetrical chest movement is a sign of respiratory distress in the newborn, as it indicates unequal lung expansion or airway obstruction. A respiratory rate of 50 breaths/minute (choice B) is normal for a newborn, as is acrocyanosis (choice C), which is a bluish discoloration of the hands and feet due to immature peripheral circulation. Short periods of apnea (less than 15 seconds) (choice D) are also common and benign in newborns unless they are associated with bradycardia or cyanosis.

Choice B is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.

Choice C is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.

Choice D is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.

A. Encourage the client to nurse more frequently so her milk will come in B. Report the client's temperature elevation C. Ask the client to empty her bladder D. Increase IV fluids

Correct Answer is C

Explanation

ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.

Choice A is not correct because the client's milk will come in regardless of nursing frequency.

Choice B is not correct because the client's temperature is within normal limits.

Choice D is not correct because there is no indication of an increase in IV fluids.

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A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

Correct Answer is A

Explanation

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is:

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

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Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent?

The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?