Methergine is prescribed for a woman to treat postpartum hemorrhage.
Before administration of this medication, the priority nursing assessment is to check the:

Blood pressure.

Uterine tone.

Deep tendon reflexes.

Amount of lochia.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Methergine (methylergonovine) is an oxytocic medication that causes vasoconstriction and increases blood pressure. It is contraindicated in clients with hypertension. Therefore, assessing the client's blood pressure before administration is crucial to ensure safety. Normal adult blood pressure is typically less than 120/80 mmHg.

Choice B rationale

Assessing uterine tone is important in managing postpartum hemorrhage, as a boggy uterus contributes to bleeding. However, before administering a medication that affects blood pressure, the blood pressure itself is the priority assessment due to the contraindications of Methergine in hypertensive clients.

Choice C rationale

Deep tendon reflexes are assessed in the postpartum period, particularly for clients with preeclampsia who are at risk for magnesium sulfate toxicity. While important, it is not the priority assessment before administering Methergine, which has a direct impact on blood pressure.

Choice D rationale

Assessing the amount of lochia is essential for monitoring postpartum bleeding. However, before administering Methergine, which can significantly increase blood pressure, ensuring the client does not have a contraindication related to hypertension is the most critical immediate assessment. .

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Correct Answer is A

Explanation

Choice A rationale

A firm fundus displaced to the right and above the umbilicus often indicates a full bladder. The bladder, when distended, can push the uterus out of its midline position and interfere with its ability to contract effectively, potentially leading to increased bleeding. Having the client void will relieve the pressure on the uterus, allowing it to return to its midline position and remain firm.

Choice B rationale

Starting a pad count is a useful way to quantify the amount of lochia, but it does not address the immediate issue of the displaced fundus and potential bladder distention. It would be a subsequent step to monitor the bleeding after addressing the fundal position.

Choice C rationale

While fundal massage is appropriate for a soft or boggy uterus, the assessment indicates the fundus is already firm. Massaging a firm uterus is not the priority and will not address the displacement caused by a likely full bladder.

Choice D rationale

Notifying the healthcare provider is necessary if the fundus remains displaced and elevated after the client voids, as this could indicate other complications. However, the initial action should be to address the most likely cause, which is bladder distention.

A. Reactive Non-stress test. B. Non-reactive Non-stress test. C. Negative Non-stress test. D. Positive Non-stress test.

Correct Answer is A

Explanation

Choice A rationale

A reactive non-stress test indicates fetal well-being. The criteria for a reactive NST in a fetus greater than 32 weeks gestation include two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline lasting for at least 15 seconds within a 20-minute period. The baseline fetal heart rate should be within the normal range of 110 to 160 beats per minute. This client's results meet these criteria.

Choice B rationale

A non-reactive non-stress test lacks the required number of fetal heart rate accelerations or the accelerations do not meet the amplitude or duration criteria within the specified time frame. This suggests the fetus may be experiencing some form of stress and requires further evaluation.

Choice C rationale

A negative non-stress test is not a standard term used to describe NST results. The test is categorized as either reactive (indicating fetal well-being) or non-reactive (suggesting potential fetal compromise).

Choice D rationale

A positive non-stress test is also not a standard term used for NST interpretation. A positive result in fetal monitoring typically refers to a contraction stress test where late decelerations are observed, indicating potential uteroplacental insufficiency.

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Methergine is prescribed for a woman to treat postpartum hemorrhage.Before administration of this medication, the priority nursing assessment is to check the:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assessing a postpartum client's fundus finds it firm, 2 centimeters above the umbilicus and displaced to the right.What is the most appropriate nursing intervention at this time?

Correct Answer is A

Explanation

When performing a Non-Stress test, the nurse interprets the finding of two accelerations of the fetal heart rate of 15 beats per minute above the baseline rate of 135 beats per minute lasting for 15 seconds in 20 minutes.This should be documented as:

Correct Answer is A

Explanation

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Methergine is prescribed for a woman to treat postpartum hemorrhage.Before administration of this medication, the priority nursing assessment is to check the:

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Methergine is prescribed for a woman to treat postpartum hemorrhage.
Before administration of this medication, the priority nursing assessment is to check the: