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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.

Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.

Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.

Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.

A. Position client in left lateral recumbent position to expose buttocks. B. Chill the enema solution to help reduce the client's fever. C. Encourage client to retain solution for at least 5 minutes. D. Insert lubricated tip of tubing 3 to 4 inches into the rectum.

Correct Answer is ["A","C","D"]

Explanation

Choice A: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice B: Chilling the enema solution is not recommended because it can cause cramping, discomfort, and vasoconstriction, which may interfere with the client's fever assessment.

Choice C: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice D: Inserting the lubricated tip of tubing 3 to 4 inches into the rectum prevents injury to the rectal mucosa and ensures proper placement of the tubing.

Choice E: Clamping the enema administration tubing after filling the enema bag is unnecessary and may cause air to enter the tubing, which can increase the risk of abdominal distension and gas pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving morning report about four clients, which client should the nurse attend to first?

Correct Answer is D

Explanation

The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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