A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin.The client reports that they have been bleeding excessively.
Which of the following actions should the nurse take?

Elevate the head of the client's bed.

Administer a dose of terbutaline.

Initiate oxygen at 2 L/min via nasal cannula.

Initiate an infusion of oxytocin.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.

Choice B rationale

Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.

Choice C rationale

Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.

Choice D rationale

Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.

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Correct Answer is C

Explanation

Choice A rationale

Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.

Choice B rationale

Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.

Choice C rationale

Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.

Choice D rationale

Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.

A. Teach the client patterned breathing techniques. B. Encourage the support person to perform effleurage. C. Encourage the support person to apply sacral counterpressure. D. Teach the client to use guided imagery.

Correct Answer is C

Explanation

Choice A rationale

Patterned breathing techniques can help in managing pain by focusing on controlled breathing, reducing anxiety, and providing a distraction from the pain, but are not specifically targeting back labor pains.

Choice B rationale

Effleurage involves light circular strokes on the abdomen and can help in managing general labor pain, but may not be as effective specifically for back labor pains.

Choice C rationale

Sacral counterpressure involves applying steady pressure to the sacral area, which can help relieve pain caused by back labor by counteracting the discomfort experienced in this area.

Choice D rationale

Guided imagery involves using mental visualization to distract from pain and promote relaxation, but may not be as effective in relieving the specific pain associated with back labor.

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A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin.The client reports that they have been bleeding excessively.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin.The client reports that they have been bleeding excessively.
Which of the following actions should the nurse take?