A woman is brought to the labor and delivery unit after delivering a full term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first?
Perform a fundal massage.
Draw blood for hemoglobin and hematocrit.
Obtain a complete obstetrical history.
Inspect the perineum for lacerations.
The Correct Answer is A
Choice A: Performing a fundal massage is the first priority in this situation to assess and manage uterine tone and prevent postpartum hemorrhage.
Choice B: Drawing blood for hemoglobin and hematocrit can be important but is not the immediate priority when the client has just delivered outside the hospital.
Choice C: Obtaining a complete obstetrical history is important but can be done after addressing the immediate postpartum concerns.
Choice D: Inspecting the perineum for lacerations is also important but should be done after addressing uterine tone and hemorrhage prevention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Applying restraints should not be the first approach in fall prevention and is associated with risks and ethical considerations.
Choice B: Accompanying residents during ambulation is a helpful practice but may not be feasible at all times. It's essential to promote independence when possible.
Choice C: Encouraging clients to wear rubber-soled shoes is an important fall prevention measure, as it can provide better traction and stability when walking.
Choice D: Leaving the hall lights on during the night may be helpful, but it is not the most critical intervention for fall prevention. Proper footwear and other measures should take precedence.
Correct Answer is C
Explanation
Choice A: CPR is important but should be performed in conjunction with defibrillation. Since two defibrillation shocks have already been administered, the next step should be another shock.
Choice B : Obtaining an arterial blood gas sample is not the immediate priority when the client is in ventricular fibrillation. Defibrillation should be continued.
Choice C: Performing the third defibrillation shock is the next appropriate step in the advanced cardiac life support (ACLS) algorithm for ventricular fibrillation.
Choice D: Administering an IV bolus of epinephrine may be part of the ACLS protocol, but it is typically administered after defibrillation attempts.
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