While you are taking Monique's vital signs and performing a postpartum assessment 4 hours after delivery, she tells you she is feeling lightheaded.
She has a history of chronic hypertension and obesity.
Her vital signs are blood pressure 85/57 mm Hg, pulse 132, respirations 28, oxygen saturation 94%. Her uterus is boggy at midline, 1 cm above the umbilicus.
What would be your next steps and anticipated orders?

Massage her fundus until firm and ensure IV access.

Orders for methylergonovine (Methergine) 0.2 mg IM and an oxytocin bolus.

Orders for carboprost tromethamine (Hemabate) 250 mcg IM. .

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Massaging the fundus helps to stimulate uterine contractions, reducing bleeding and promoting firmness in the uterus. Ensuring IV access is critical for administering medications and fluids quickly.

Choice B rationale

Methylergonovine (Methergine) is used to prevent and control postpartum hemorrhage by promoting uterine contractions. Oxytocin bolus also helps stimulate contractions, preventing further blood loss.

Choice C rationale

Carboprost tromethamine (Hemabate) is another uterotonic agent used to control severe postpartum hemorrhage by causing uterine contractions. Its use depends on the patient's response to other treatments.

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Correct Answer is C

Explanation

Choice A rationale

While maternal lacerations are a risk during childbirth, they are not the greatest risk in cases of fetal dystocia. The focus is primarily on fetal wellbeing.

Choice B rationale

Fetal injury such as bruising can occur with dystocia, but the primary concern is the potential for severe, life-threatening complications.

Choice C rationale

Neonatal asphyxia related to prolonged labor is the greatest risk with fetal dystocia. Prolonged labor can lead to decreased oxygen supply to the fetus, causing asphyxia and potential brain injury.

Choice D rationale

Increased consideration for a cesarean delivery is a possible outcome of fetal dystocia, but it is a management decision rather than a direct risk to the baby’s immediate health.

A. Extension of the episiotomy is performed. B. Signs of fetal compromise have resolved. C. The "three-pull" rule has been achieved. D. Patient is under full anesthesia status.

Correct Answer is C

Explanation

Choice A rationale

Extension of the episiotomy is not a guideline for vacuum-assisted delivery. Episiotomy extension is considered based on perineal conditions during delivery, not as a primary guideline for vacuum procedures.

Choice B rationale

Signs of fetal compromise resolving is critical for fetal safety but isn't specific to the guidelines for a vacuum-assisted delivery. Continuous fetal monitoring assesses for compromise, not just vacuum application.

Choice C rationale

The "three-pull" rule refers to the number of attempts allowed with the vacuum to avoid excessive force and trauma. This guideline ensures safety during the procedure, preventing overuse of vacuum pressure.

Choice D rationale

Full anesthesia status is unrelated to the guidelines for vacuum-assisted delivery. Anesthesia choices depend on patient and procedural needs, but aren't a guideline criterion for vacuum use.

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Naxlex Comprehensive Predictor Exams

The nurse is providing care for a patient in the second phase of labor.After more than 4 hours of pushing, the nurse suspects fetal dystocia.Which is the greatest risk related to the nurse's suspected complication?

Correct Answer is C

Explanation

The nurse is assisting the primary care provider (PCP) with a vacuum-assisted delivery because of a prolonged second stage of labor.The nurse will inform the PCP when which guideline of the procedure is met?

Correct Answer is C

Explanation

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?

A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast.Upon inspection, a diagnosis of mastitis is made.Which of the following nursing interventions is appropriate?

When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to:

The antepartum nurse has just received shift report on four pregnant clients at 0700.Which of the clients should the nurse assess first?

Which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor?