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Exhibits

Based on the assessment data, the nurse recognizes the need to intervene immediately.

Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Notify primary healthcare provider

Count saturated pads per hour

Administer 2 units of packed red blood cells (PRBC)

Administer 0.2 mg methylergonovine IM

Insert straight catheter

Alert the emergency response team

Increase the IV fluid to maximum rate

Weigh all bloody materials

Massage fundus until firm

Answer and Explanation

Correct Answer : A,B,D,F,G,I

A.Notify primary healthcare provider
The client's vital signs indicate signs of potential hypovolemic shock (low blood pressure, tachycardia, fever), and the saturated pad and sheets suggest ongoing significant bleeding. Notifying the primary healthcare provider is crucial to obtain further orders and potentially escalate care.
B.   Count saturated pads per hour
Counting saturated pads per hour provides a quantitative assessment of blood loss and helps monitor the effectiveness of interventions aimed at reducing bleeding. This ongoing assessment guides further management decisions.
C.   Administer 2 units of packed red blood cells (PRBC)

While blood loss is significant, initiating a blood transfusion is not typically an immediate first-line intervention unless the client shows signs of severe hemorrhagic shock or ongoing bleeding that cannot be controlled by other measures.
D.   Administer 0.2 mg methylergonovine IM
Methylergonovine is a medication used to promote uterine contraction and control postpartum hemorrhage. Given the boggy fundus and significant bleeding, administering methylergonovine IM helps to contract the uterus and reduce bleeding.
E.   Insert straight catheter
While maintaining accurate fluid balance is important, inserting a straight catheter is not an immediate priority compared to addressing active hemorrhage and stabilizing the client's condition.
F.   Alert the emergency response team
The client's condition, with a boggy fundus, saturated pads, and ongoing bleeding, indicates a need for urgent intervention beyond routine measures. Alerting the emergency response team ensures prompt assistance and resources for managing potential hemorrhagic shock.
G.   Increase the IV fluid to maximum rate
Increasing IV fluid administration helps to restore circulating volume and stabilize the client's blood pressure. This is essential in managing hypovolemia resulting from significant postpartum hemorrhage.
H.   Weigh all bloody materials
Weighing all bloody materials is a method to estimate blood loss but is not as urgent as direct interventions aimed at stopping bleeding and stabilizing the client.
I.   Massage fundus until firm
Massaging the fundus helps to stimulate uterine contractions, which can help control bleeding by compressing blood vessels at the placental site. A boggy fundus indicates poor uterine tone, and firming it up is crucial to prevent further hemorrhage.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Rationale

A. This allows the client time to process their emotions. A diagnosis with a chronic illness can be overwhelming.

B. Referring the client to a social worker for support therapy is a good idea for ongoing emotional support and counseling. However, at this moment, the client might need immediate assistance

C. While relaxation techniques can be helpful in managing stress and anxiety, they might not address the immediate need for insulin administration education.

D. Explaining the importance of insulin, is crucial, but it may not be effective if the client is not in a receptive state.

A. Blood pressure 90/62 mm Hg B. Oxygen saturation of 89% C. Fundus rotated to the right D. Voided 200 mL of clear yellow urine E. Oxygen saturation of 89% F. IV infusing at 125 ml/hr

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

Explanation

Blood pressure 90/62 mm Hg

A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.

Oxygen saturation of 89%

An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.

Fundus rotated to the right

The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.

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Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

Correct Answer is A

Explanation

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

Explanation

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Exhibits

Based on the assessment data, the nurse recognizes the need to intervene immediately.

Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.