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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Praising the client for weight loss without knowing the underlying cause may not be appropriate. Rapid and unexplained weight loss can be a sign of underlying health issues.
Choice B: Advising the client to schedule an appointment with a healthcare provider is the most appropriate action. Rapid and unexplained weight loss should be evaluated by a healthcare professional to identify any potential underlying health concerns.
Choice C: Advising the client to begin taking a multivitamin daily does not address the underlying cause of the weight loss and may not be the most appropriate action.
Choice D: Documenting the client's reason for using the herb is important but should be accompanied by further evaluation and intervention by a healthcare provider due to the significant weight loss.
Correct Answer is D
Explanation
Choice A rationale: Referring the client to a dietitian for nutrition education is a proactive step. Dietitians can provide personalized guidance and address the client's dietary concerns and preferences. However, this alone may not be sufficient if the client is strongly resistant to dietary changes.
Choice B rationale: Providing pamphlets about heart-healthy diet selections is informative but may not effectively address the client's resistance to dietary changes. The client's reluctance needs to be explored and addressed through a more interactive approach.
Choice C rationale: While exercise is important for heart health, the primary concern here is the client's elevated cholesterol levels, which are significantly impacted by dietary choices. Suggesting exercise alone may not adequately address the issue at hand.
Choice D rationale: Discussing the client's concerns about the change in diet is the most appropriate initial action. It allows the nurse to understand the client's perspective, identify barriers to compliance, and work collaboratively with the client to develop a plan that considers his preferences and challenges. This approach is more likely to lead to a successful change in diet and lifestyle compared to simply providing information or referrals.
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