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A 36-year-old patient who is gravida 5 para 5 (G5P5) was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.
She was in labor for 25 hours and forceps were used to assist with the delivery.
She was given an epidural for anesthesia that was effective.
The labor and delivery nurse reported that the patient had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.
Her vital signs were stable.
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 recent assessment.

Administer 0.2 mg methylergonovine IM

Notify primary healthcare provider

Insert straight catheter

Massage fundus until firm

Count saturated pads per hour

Administer 2 units of packed red blood cells (PRBC)

Increase the IV fluid to maximum rate

Weigh all bloody materials .

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A rationale

Methylergonovine is used after childbirth to help control bleeding and improve muscle tone in the uterus. Administering 0.2 mg of methylergonovine IM can help to control postpartum hemorrhage in this patient.

Choice B rationale

Notifying the primary healthcare provider is crucial in this situation. The healthcare provider needs to be aware of the patient’s condition and the interventions being initiated.

Choice C rationale

Inserting a straight catheter can help to manage urinary retention, which could be a potential issue given the patient’s prolonged labor and use of epidural anesthesia.

Choice D rationale

Massaging the fundus until it is firm can help to stimulate uterine contractions, which can control bleeding and prevent postpartum hemorrhage.

Choice E rationale

Counting saturated pads per hour can help to monitor the amount of bleeding and assess the effectiveness of the interventions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale

Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.

Choice B rationale

A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.

Choice C rationale

Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.

Choice D rationale

Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.

A. Advise family members to monitor for symptoms of illness for two weeks after their last contact with the patient. B. Implement droplet precautions, place the patient in a private room, and keep the door closed. C. Inform the patient to notify others that they may have been potentially exposed in the past 14 days. D. Initiate an IV infusion for the administration of an antiviral drug in case of a positive COVID-19 test result.

Correct Answer is B

Explanation

Choice A rationale

While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.

Choice B rationale

Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.

Choice C rationale

Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.

Choice D rationale

Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.

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Naxlex Comprehensive Predictor Exams

A parent brings a 4-month-old infant to the clinic.The infant has had a runny nose, a slight fever, and a cough for the last two days.Which of the following findings should alert the nurse that the child is in acute respiratory distress?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

A nurse is providing dietary advice to a patient with hypertension.Which food item would be the best choice for the patient’s lunch?

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?

A patient has been prescribed 1 L of Lactated Ringer’s IV to be infused over a 12-hour period. The IV administration set delivers 15 gtt/mL. What should be the infusion rate in gtt/min? (Provide a numerical value only. If rounding is required, round to the nearest whole number.)

What advice should a nurse give to a patient who is about to undergo a cystoscopy?

A patient is admitted to the mental health unit due to feelings of depression following a positive HIV diagnosis.Which action should the nurse take to ensure a safe environment for this patient?

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.