A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

Massage the client's fundus.

Insert an indwelling urinary catheter.

Administer oxygen at 10 L/min

Elevate the client's right hip

Answer and Explanation

The Correct Answer is A

A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.

B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.

C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.

D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.

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Correct Answer is A

Explanation

The correct answer is A. Emotional lability.

A. Emotional lability: Emotional lability refers to rapid and unpredictable changes in mood, with intense emotions shifting quickly from one extreme to another. It is a common aspect of the emotional adaptation to pregnancy and is often influenced by hormonal changes.

B. Focusing phase: The focusing phase is a concept related to the process of adapting to pregnancy. It involves the pregnant individual focusing on the reality of the pregnancy and incorporating the changes into their self-concept. While mood changes may occur during this phase, the client's statement more specifically reflects emotional lability.

C. Cognitive restructuring: Cognitive restructuring involves changing thought patterns to modify emotional responses. The client's statement does not necessarily indicate a deliberate process of changing thought patterns but rather describes the emotional swings often associated with pregnancy.

D. Couvade syndrome: Couvade syndrome refers to a phenomenon where a partner experiences symptoms that mimic pregnancy symptoms. It is not applicable in this context as the client is describing her own emotional experiences related to pregnancy.

A. "You will need to drink the glucose solution 2 hours prior to the test." B. "Limit your carbohydrate intake for 3 days prior to the test." C. "A blood glucose of 130 to 140 is considered a positive screening result. D. "You will need to fast for 12 hours prior to the test

Correct Answer is C

Explanation

Choice A Reason:

Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.

Choice B Reason:

Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.

Choice C Reason:

C. “A blood glucose of 130 to 140 is considered a positive screening result.”

In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of135 mg/dL or higheris considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.

Choice D Reason:

Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.

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A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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