A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV oxytocin is infused. When notifying the healthcare provider of the client's condition, which information is most important for the nurse to provide?

Maternal apical heart rate.

Maternal blood pressure.

Time oxytocin infusion completed.

Total amount of oxytocin infused.

Answer and Explanation

The Correct Answer is C

A. Maternal apical heart rate: While monitoring the maternal heart rate is important, the primary concern in this scenario is the timing of the oxytocin infusion in relation to the onset of bleeding. The time of the infusion helps determine if there is a correlation with the excessive bleeding.

B. Maternal blood pressure: Blood pressure is important for assessing hemodynamic stability, especially in cases of hemorrhage, but the most important immediate information would be related to the timing of the oxytocin infusion, as this could help determine if it is a contributing factor to the bleeding.

C. Time oxytocin infusion completed: The timing of the oxytocin infusion is the most important piece of information to provide. If the bleeding began after the infusion, the healthcare provider can consider oxytocin as a potential cause of uterine atony or other complications.

D. Total amount of oxytocin infused: While the total amount of oxytocin administered is important, the timing of the infusion is more critical in understanding the connection between the oxytocin administration and the onset of bleeding.

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Correct Answer is B

Explanation

A. Almost all women at 28-weeks gestation have anemia: While anemia is common in pregnancy, it is not typical for all women to have it. The nurse should provide specific information relevant to the client’s current values rather than generalizing.

B. Plasma volume increases, making the blood count appear low: During pregnancy, plasma volume increases significantly, which can dilute the blood and result in a lower hemoglobin and hematocrit level, even though the client may not have true anemia. This is a normal physiological change and is known as "physiological anemia of pregnancy."

C. Increasing intake of protein might improve these values: Protein intake is important during pregnancy, but it primarily supports tissue growth and development rather than directly improving hemoglobin or hematocrit levels.

D. It might be necessary to take an iron supplement twice daily: The client’s values are not significantly low enough to automatically recommend twice-daily iron supplements. The nurse should first explain the normal physiological changes in pregnancy before suggesting supplementation.

A. Urge the client to have regular STI screening every two years. B. Clarify that all STIs are transmitted through sexual intercourse. C. Discuss that partners without similar symptoms may not be infected. D. Answer questions directly and correct any misinformation.

Correct Answer is D

Explanation

A. Urge the client to have regular STI screening every two years: While regular STI screenings are important, the client should be encouraged to get tested more frequently based on risk factors rather than waiting every two years. Regular testing should be based on the client's sexual activity and risk exposure.
B. Clarify that all STIs are transmitted through sexual intercourse: While many STIs are transmitted through sexual intercourse, some (like HPV) can also be spread through skin-to-skin contact. It’s important to provide accurate information specific to HPV transmission.
C. Discuss that partners without similar symptoms may not be infected: This is inaccurate. Many STIs, including HPV, can be asymptomatic. Even if a partner does not show symptoms, they could still be infected and capable of transmitting the virus.
D. Answer questions directly and correct any misinformation: The nurse should provide accurate, clear, and compassionate answers to the client’s questions. Correcting misinformation helps the client make informed decisions and manage their health appropriately.

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Body System	Nurses Notes and Flow Sheet
Respiratory	Respirations 16 breaths/minute Oxygen saturation of 89% Several deep breaths
Integumentary	Episiotomy intact with no redness Pad is saturated with blood 18 gauge IV to left forearm
Circulatory	Heart rate 96 beats/minute Blood pressure 90/62 mm Hg IV infusing at 125 mL/hr
Genital/Urinary	Boggy fundus 1 cm above umbilicus Fundus rotated to the right Voided 200 mL of clear yellow urine

A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV oxytocin is infused. When notifying the healthcare provider of the client's condition, which information is most important for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having sex with someone who had many partners. Which response should the nurse provide?

Correct Answer is D

Explanation

The nurse is preparing to teach a class on breast self-examination. In describing the "at-risk" individual, the nurse should describe which woman as having the highest risk of developing breast cancer?

Which should be the primary focus of nursing care in the active phase of labor for a client who anticipates an unmedicated delivery?

A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV oxytocin is infused. When notifying the healthcare provider of the client's condition, which information is most important for the nurse to provide?

A client at 8-weeks gestation has a hemoglobin of 9.5 g/dl (5.9 mmol/L). Which nursing intervention has the highest priority? Reference Range: Hemoglobin (Hgb) [Pregnant female: greater than 11 g/dL (110 g/L)

The nurse is caring for a laboring client who is group B Streptococcus positive (GBS+). Which immediate treatment is indicated for this client?