How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.

Which of the following actions should the nurse take first?

A.

Collect hemoglobin and hematocrit levels.

B.

Insert an indwelling urinary catheter.

C.

Administer oxygen via face mask at 10 L/min.

D.

Prepare the client to receive a plasma expander.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

  • Color: Consistent with genetic background

    • Interpretation: B) Sign of potential improvement
    • Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.

  • Axillary Temperature: 36.3°C (97.4°F)

    • Interpretation: B) Sign of potential improvement
    • Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.

  • Reflex Irritability: Cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.

  • Muscle Tone: Flaccid

    • Interpretation: C) Sign of potential worsening condition
    • Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.

  • Respiration Effort: Good cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.

  • Heart Rate: 140/min

    • Interpretation: B) Sign of potential improvement
    • Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Correct Answer is A

Explanation

Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register