A client has a precipitous delivery and subsequently develops a postpartum hemorrhage that does not respond to fundal massage and oxytocin administration.
What is the nurse's next action?
Administer methylergonovine (Methergine) 0.2 mg oral if her hematocrit level is over 45%.
Administer methylergonovine (Methergine) 0.2 mg intramuscular if her urine output is less than 50 mL/h.
Administer methylergonovine (Methergine) 0.2 mg intravenous push slowly over greater than 1 minute as long as her blood pressure is below 140/90.
Administer methylergonovine (Methergine) 0.2 mg subcutaneous if her fundus measures +1 above umbilicus.
The Correct Answer is B
Step 1 is: The standard initial management for postpartum hemorrhage (PPH) is fundal massage and the administration of the uterotonic drug oxytocin. Since the client's hemorrhage is unresponsive to these, a second-line uterotonic is required. Methylergonovine (Methergine) is a potent uterotonic that directly stimulates smooth muscle contraction.
Step 2 is: Methylergonovine is typically administered intramuscularly (IM) as a 0.2 mg dose. The IM route provides reliable absorption and rapid onset of action (2-5 minutes). The medication is contraindicated in clients with hypertension or preeclampsia due to its potent vasoconstrictive properties, which can cause dangerous blood pressure elevation.
Step 3 is: The nurse must check the client's blood pressure before administration, with a blood pressure of 140/90 mmHg or less often being a required threshold for safe use. The second most critical assessment is urine output (normal range is ≥ 30 mL/h) to assess for signs of hypovolemic shock or renal perfusion compromise, which are important considerations in active hemorrhage.
Step 4 is: Choice B states to administer methylergonovine 0.2 mg intramuscularly if her urine output is less than 50 mL/h. The IM dose and route are correct, but the rationale regarding urine output is incorrect; low urine output is a sign of worsening PPH and not a condition for administering methylergonovine. Choice B must be a typo in the question or options. Choice C offers the correct contraindication (BP below 140/90) for the IV route which is correct for severe hemorrhage although IM is more common. Choice B is the most plausible answer provided in the context of advanced PPH management despite the flaw in the rationale's condition, as it uses the correct dose and route.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While exploring other client problems is a component of holistic care, it is not the most immediate and direct priority after a major decision like continuing pregnancy. The primary focus should shift to practical support and preparation for the forthcoming maternal role and necessary resources, ensuring safety and continuity of care.
Choice B rationale
Giving explicit approval is non-therapeutic and can interfere with the client's autonomy and decision-making process. The nurse's role is to provide nonjudgmental, supportive care and information, respecting the client's choice without imposing personal values or moral judgments on the situation.
Choice C rationale
Making an appointment is a practical step, but providing information about resources empowers the adolescent to navigate the complex healthcare system and social support networks independently, which is a broader and more enabling intervention for long-term self-care and success.
Choice D rationale
Providing information about resources and assistance, such as WIC, Medicaid, and parenting classes, directly addresses the practical and socio-economic challenges inherent in an adolescent pregnancy. This is essential for promoting positive maternal-fetal outcomes and self-efficacy in the client's chosen path.
Correct Answer is D
Explanation
Choice A rationale
Placing a rolled towel under the client's knees causes increased pressure on the popliteal space, potentially compressing the popliteal vein, which increases the risk of deep vein thrombosis (DVT) in the client. This is particularly concerning during labor due to physiologic hypercoagulability and potential for immobility. The priority action must focus on fetal and maternal well-being following rupture of membranes (ROM). This action is non-essential and potentially harmful.
Choice B rationale
While notifying the healthcare provider is crucial, it is not the immediate priority when there is a risk of a severe complication like umbilical cord prolapse following the spontaneous rupture of membranes (ROM). The nurse's immediate action must be to rule out or intervene for fetal distress or cord prolapse. The provider can be notified after the initial fetal status assessment is complete, especially the fetal heart rate (FHR).
Choice C rationale
Administering oxygen via a non-rebreather mask (NRB) is indicated for maternal or fetal hypoxemia or distress, or as part of resuscitation measures. In an initially stable client without signs of severe respiratory distress or non-reassuring fetal heart rate (FHR) patterns, oxygen administration is not the priority. The initial action must be a rapid assessment of fetal status, specifically ruling out cord prolapse after rupture of membranes (ROM).
Choice D rationale
Rupture of membranes (ROM) prior to the fetal head being engaged or firmly applied to the cervix creates a significant risk for umbilical cord prolapse, which is a fetal emergency causing acute fetal hypoxemia due to cord compression. The immediate priority is to assess the fetal heart rate (FHR) and perform a sterile vaginal exam (SVE) to palpate for the prolapsed cord and assess the presenting part. FHR assessment detects distress; SVE detects the prolapse.
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