A nurse admits a normal vaginal delivery to the maternity unit 2 hours ago.

The patient's fundus is firm at the umbilicus.

On admission, her vital signs are BP 108/64, Apical 90, RR 20, and Temp.

98.6°F. Suddenly, her lochia appears to be heavy, saturating the entire chux pad within 5 minutes.

At this time, the nurse's first priority action is:

Place the patient in a Trendelenburg position.

Notify the physician on call about the emergency.

Administer Methylergonovine 0.2 mg IM now.

Massage fundus until firm.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Placing the patient in a Trendelenburg position is not the immediate priority. This position is often used to manage shock or to improve blood flow to the brain, but it does not directly address the cause of heavy lochia. It may not be the most effective first intervention in this situation.

Choice B rationale

Notifying the physician is important, but the nurse should first attempt to control the bleeding. The physician can be notified after initial measures to stop the bleeding are taken. Immediate intervention by the nurse is crucial in this scenario to stabilize the patient.

Choice C rationale

Administering Methylergonovine can help control postpartum hemorrhage, but this should be done after attempting non-pharmacological measures like fundal massage. Methylergonovine can have side effects and should be used with caution.

Choice D rationale

Massaging the fundus until it is firm is the immediate priority. This can help expel clots and stimulate uterine contraction, which can reduce bleeding. It is a direct and immediate intervention to address the heavy lochia.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["1.2"]

Explanation

Step 1 is 3000 grams ÷ 1000 = 3 kg.

Step 2 is 3 kg × 24 mg = 72 mg.

Step 3 is 72 mg ÷ (50 mg ÷ 5 ml) = 1.2 ml.

Answer: 1.2 ml.

A. I will take antibiotics for 2-3 days until the soreness subsides. B. I can continue breastfeeding while the mastitis resolves. C. I will take analgesics to relieve some of the discomfort. D. I need to wear a supportive bra.

Correct Answer is A

Explanation

Choice A rationale

Antibiotics should be taken for the full prescribed course, typically 10-14 days, to ensure complete resolution of the infection. Stopping antibiotics early can lead to recurrence or resistance.

Choice B rationale

Continuing to breastfeed while having mastitis is encouraged as it helps keep milk flowing and prevents blockage.

Choice C rationale

Taking analgesics for pain relief is appropriate during mastitis as it helps manage discomfort and supports continued breastfeeding.

Choice D rationale

Wearing a supportive bra helps alleviate discomfort and supports the breasts, which is beneficial during mastitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Zidovudine oral solution 24 mg/kg PO BID has been ordered for a newborn at risk for HIV. On hand is 3000 grams. Calculate the amount to be administered in ml per dose.

Correct Answer is ["1.2"]

Explanation

The nurse is providing discharge teaching about the possibility of mastitis to a mother who is breastfeeding.Which statement by the client indicates a need for MORE teaching?

Correct Answer is A

Explanation

The client has a physician's order for Methylergonovine (Methergine) 0.2 mg by mouth every 6 hours for 24 hours. The RN knows the reason for this order is to assist in controlling postpartum bleeding. What is the total amount the patient will receive in mg in a 24-hour period?

A nurse is caring for a client who is considering several methods of contraception.Which method should the nurse identify as being most reliable?

A 35-year-old patient is getting her labs drawn at the six weeks post-partum check-up. Upon assessment, the nurse notes swelling in the patient's left leg, and the patient reports pain and tenderness in the calf.The nurse knows which lab results are responsible?

A nurse is caring for a mother who delivered vaginally 2 hr ago. 38 week gestation.Vaginal delivery of a 9-pound 8-ounce baby girl. Select the 4 findings the nurse should report to the provider.

The nurse is assessing a 40-week small for gestational age (SG

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling "down" and sad, having no energy, and wanting to cry.Which of the following is a priority action by the nurse?

A nurse is caring for a newborn who is 56 hours old.Vital signs at 0700: Heart rate 168/min, Respiratory rate 70/min, Temperature 36.1°C (97.0°F), Oxygen saturation 97%. The nurse reviews the assessment findings and determines the findings are consistent with which of the following complications?