A nurse is planning care for a client who is 1 hour postpartum and has peripartum cardiomyopathy.
Which of the following actions should the nurse plan to take?
Administer an IV bolus of lactated Ringer’s.
Assess blood pressure twice daily.
Restrict daily oral fluid intake.
Obtain a prescription for misoprostol.
The Correct Answer is C
Choice A rationale
Administering an IV bolus of lactated Ringer’s is not the best action for a client with peripartum cardiomyopathy. This condition is a form of heart failure that occurs during the last month of pregnancy or up to five months postpartum. It can lead to fluid overload, so giving an IV bolus of lactated Ringer’s could exacerbate the client’s condition.
Choice B rationale
Assessing blood pressure twice daily is important for any postpartum client, but it is not the most critical action for a client with peripartum cardiomyopathy. This condition can lead to fluid overload and heart failure, so while monitoring blood pressure is important, it is not the primary intervention.
Choice C rationale
Restricting daily oral fluid intake is the correct action. Peripartum cardiomyopathy can lead to fluid overload and heart failure. Restricting fluid intake can help manage the client’s fluid status and prevent exacerbation of heart failure.
Choice D rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to prevent stomach ulcers in patients taking NSAIDs and to induce labor or cause an abortion. It has no role in the management of peripartum cardiomyopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Peripheral edema 2+ in bilateral lower extremities is a common finding in the postpartum period and does not necessarily indicate a problem. It can result from the normal fluid shifts that occur after delivery.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated and could indicate the development of postpartum hypertension, a condition that can lead to serious complications such as stroke. This finding necessitates immediate follow-up.
Choice C rationale
Lateral deviation of the uterus could indicate a full bladder, which can interfere with uterine contractions and lead to increased bleeding. This finding necessitates immediate follow-up.
Choice D rationale
Deep tendon reflexes 1+ are within normal limits and do not necessitate immediate follow-up.
Choice E rationale
A large amount of lochia rubra could indicate postpartum hemorrhage, a potentially life- threatening condition. This finding necessitates immediate follow-up.
Correct Answer is B
Explanation
Choice A rationale
Providing the newborn with 15 mL glucose water after each feeding is not a recommended action for a newborn undergoing phototherapy for jaundice. While maintaining adequate hydration is important, feedings should consist of breast milk or formula, unless otherwise directed by a healthcare provider.
Choice B rationale
Before starting phototherapy, it’s important to protect the newborn’s eyes from the light by applying eye patches. This can help prevent potential damage to the retinas.
Choice C rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not a recommended action for a newborn undergoing phototherapy for jaundice. The light needs to be able to penetrate the skin in order to break down the bilirubin, and applying lotion could potentially interfere with this process.
Choice D rationale
Turning the newborn every hour is not a recommended action for a newborn undergoing phototherapy for jaundice. While it’s important to change the newborn’s position regularly to ensure that all areas of the skin are exposed to the light, this does not need to be done on an hourly basis.
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