A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.

What should the nurse do first?

Administer Oxytocin to the client

Massage the client’s fundus

Provide oxygen to the client via non-rebreather face mask

Empty the client’s bladder

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering Oxytocin to the client is an important intervention for postpartum hemorrhage, but it is not the first action the nurse should take. Oxytocin stimulates uterine contractions which can help control bleeding, but it should be administered after the initial steps of assessing the uterus and ensuring it is firm.
Choice B rationale
Massaging the client’s fundus is the priority action to address excessive vaginal bleeding. A firm, well-contracted uterine fundus often helps to control postpartum bleeding. If the uterus is not well contracted, gentle massage is often sufficient to stimulate contractions. If the uterus does not respond to massage, then further interventions such as administering Oxytocin may be necessary.
Choice C rationale
Providing oxygen to the client via a non-rebreather face mask is an intervention that might be necessary if the client shows signs of hypoxia or shock as a result of the bleeding. However, it is not the first action that should be taken.
Choice D rationale
Emptying the client’s bladder is important as a distended bladder can displace the uterus and interfere with contractions, leading to increased bleeding. However, this is not the first action to take.

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Correct Answer is C

Explanation

Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.

A. “WBC Count 11,000/mm (5,000 to 10,000/mm?).”. B. “Fasting blood glucose 180 mg/dL (74 to 106 mg/dL).”. C. “Hematocrit 37% (37% to 47%).”. D. “Creatinine 0.9 mg/dL (0.5 to 1 mg/dL).”.

Correct Answer is B

Explanation

Choice A rationale
A WBC count of 11,000/mm is slightly above the normal range (5,000 to 10,000/mm), but it is not uncommon for the WBC count to increase during pregnancy due to physiological changes and increased stress on the body. However, a significantly elevated WBC count could indicate an infection or other medical condition, so it should be monitored closely.
Choice B rationale
A fasting blood glucose level of 180 mg/dL is significantly above the normal range (74 to 106 mg/dL), indicating hyperglycemia. This could be a sign of gestational diabetes, a condition that can develop during pregnancy and cause high blood sugar levels. Gestational diabetes can increase the risk of various pregnancy complications, including preeclampsia, premature birth, and having a baby with a high birth weight. Therefore, this finding should be reported to the provider immediately.
Choice C rationale
A hematocrit level of 37% is within the normal range (37% to 47%), so it would not typically be a cause for concern.
Choice D rationale
A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL), so it would not typically be a cause for concern.

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A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a term newborn who is 48 hours old. The mother has a history of opioid use during pregnancy and was prescribed methadone. Based on the findings 24 hours later, how should the nurse interpret the findings?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.

What should the nurse do first?