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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While addressing the client's feelings is important, dismissing the need for blood pressure monitoring is not appropriate nursing practice during pregnancy. Routine blood pressure checks are essential for detecting potential complications.
Choice B rationale
While blood pressure can increase in the second trimester due to physiological changes like increased blood volume, it doesn't invariably increase early in the second trimester, and this statement might cause unnecessary alarm if the client's blood pressure is currently normal.
Choice C rationale
Advanced maternal age (typically over 35) is a risk factor for gestational hypertension, but stating this directly without knowing the client's baseline blood pressure or other risk factors might be alarming and isn't the primary reason for routine monitoring at every prenatal visit.
Choice D rationale
Routine blood pressure monitoring is a standard component of prenatal care for all pregnant clients, regardless of their past medical history or perceived risk. This allows for the early detection of gestational hypertension or preeclampsia, which can develop even in women with previously normal blood pressure. Early detection and management are crucial for maternal and fetal well-being.
Correct Answer is ["B","F","G"]
Explanation
Choice B rationale
Prostaglandin administration, either vaginally or orally, helps to ripen the cervix by increasing collagenase activity and water content, leading to cervical softening, thinning (effacement), and dilation, which are necessary for labor to begin.
Choice F rationale
Amniotomy, or artificial rupture of membranes (AROM), involves the deliberate rupture of the amniotic sac. This can stimulate labor by releasing prostaglandins, increasing uterine contractility, and allowing the presenting part of the fetus to descend further into the pelvis, putting pressure on the cervix.
Choice G rationale
Oxytocin is a synthetic hormone that mimics the action of endogenous oxytocin, stimulating uterine contractions. It is commonly administered intravenously to initiate or augment labor once cervical ripening has occurred or the cervix is favorable.
Choice A rationale
Epidural anesthesia is a method of pain relief during labor, not a method for inducing labor. It provides regional analgesia by blocking nerve impulses in the lower body.
Choice C rationale
Bed rest is generally not recommended for labor induction and can even be counterproductive. Ambulation and positional changes can help to encourage fetal descent and uterine activity.
Choice D rationale
Vitamin supplementation is important for overall maternal and fetal health during pregnancy but does not directly stimulate uterine contractions or cervical changes necessary for labor induction.
Choice E rationale
Fetal ultrasound is used to assess fetal well-being, presentation, and amniotic fluid volume but does not initiate the process of labor induction. .
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