At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?
Start prescribed IV with lactated Ringer's.
Inform the anesthesia care provider.
Contact the client's obstetrician.
Ensure preoperative lab results are available.
The Correct Answer is B
Choice B rationale
Informing the anesthesia care provider is the priority action. Ingesting coffee within a few hours before surgery can affect anesthesia management, and the anesthesia team needs to be aware of any potential complications.
Choice A rationale
Starting the IV is important but not the priority in this scenario. The anesthesia care provider needs to be informed first.
Choice C rationale
Contacting the obstetrician is also important but comes after informing the anesthesia care provider.
Choice D rationale
Ensuring preoperative lab results are available is essential, but the first step should be to inform the anesthesia care provider about the coffee intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Latanoprost eye drops are used to reduce intraocular pressure in glaucoma patients and are not relevant for a newborn exposed to Neisseria gonorrhoeae.
Choice B rationale
Erythromycin ointment is the correct medication to administer to a newborn exposed to Neisseria gonorrhoeae. It is used to prevent ophthalmia neonatorum, an eye infection caused by the bacteria. Administering erythromycin ointment is essential to protect the newborn's eyes from potential blindness or severe infection.
Choice C rationale
Tetracaine eye drops are a topical anesthetic used to numb the eyes during procedures and are not indicated for preventing neonatal eye infections caused by Neisseria gonorrhoeae.
Choice D rationale
Neomycin ointment is an antibiotic used for treating bacterial infections, but it is not the standard treatment for preventing ophthalmia neonatorum in newborns exposed to Neisseria gonorrhoeae. Erythromycin ointment is the recommended prophylactic treatment. .
Correct Answer is D
Explanation
Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.
Choice B rationale
Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.
Choice C rationale
Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.
Choice D rationale
Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.
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