Which action is most important for the nurse to implement?

Increase IV infusion rate.

Assess the vital signs.

Massage the fundus.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.

Choice B rationale

Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.

Choice C rationale

Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.

Choice D rationale

Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.

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Correct Answer is A

Explanation

Choice A rationale

A heel stick blood glucose test is crucial for an infant showing jitteriness, hypotonicity, and weak cry as these symptoms suggest hypoglycemia which requires immediate confirmation and treatment.

Choice B rationale

Documenting findings is essential but does not address the immediate need to rule out and treat hypoglycemia in the symptomatic newborn.

Choice C rationale

Swaddling the infant provides comfort and warmth but does not address potential hypoglycemia, which is the priority in this case.

Choice D rationale

Placing a pulse oximeter monitors oxygenation but does not directly address the underlying cause of jitteriness and hypotonia, which could be hypoglycemia.

A. She may be experiencing postpartum preeclampsia. B. She may have an infection that needs further evaluation. C. Her symptoms could indicate anemia due to blood loss. D. She may be experiencing normal postpartum fatigue.

Correct Answer is A

Explanation

Choice A rationale

Postpartum preeclampsia symptoms include headache, nausea, dizziness, weakness, and visual disturbances due to increased blood pressure. Normal BP is <120/80 mmHg. Labs may show elevated liver enzymes and proteinuria.

Choice B rationale

Infections postpartum can cause fever, localized pain, and discharge but are less likely to present with headache, nausea, dizziness, and visual disturbances. Normal WBC is 4,000-11,000 cells/mcL.

Choice C rationale

Anemia due to blood loss may cause fatigue, dizziness, and weakness but usually doesn't present with headache and visual disturbances. Normal hemoglobin is 12-16 g/dL for women.

Choice D rationale

Normal postpartum fatigue generally doesn't include severe headache, nausea, dizziness, and visual disturbances. It is mainly characterized by tiredness and mild discomfort as the body recovers.

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Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

Following an amniocentesis, a client verbalizes several concerns. Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

During a routine prenatal visit, a client at 32-weeks gestation reports that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. Which action should the nurse implement?

A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?