A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.
Complete the following sentence by using the list of options. The nurse should first monitor the client's
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:
- Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
- Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.
So, the completed sentence would be:
- The nurse should first monitor the client's fundal tone followed by the client's blood pressure.
Taking care of immediate risks and stabilizing the patient is key in such cases.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Holding the newborn during the initial visit may make the older sibling feel left out or jealous. Encouraging involvement with the new baby may be more beneficial.
Choice B rationale
Spending individual time with the older sibling helps them feel valued and ensures they do not feel neglected, facilitating better acceptance of the newborn.
Choice C rationale
Having the older sibling purchase a gift for the newborn can create a positive association, but it is less impactful than ensuring individual time and attention.
Choice D rationale
Postponing the introduction until discharge can increase feelings of jealousy or resentment, as the older sibling might feel excluded from the new family dynamic during a crucial time.
Correct Answer is []
Explanation
The client is most likely experiencing an ectopic pregnancy. Here's why:
- Symptoms: The client presents with intermittent vaginal bleeding and dull left lower quadrant abdominal pain, which are common symptoms of an ectopic pregnancy.
- Physical Examination: Tenderness upon palpation in the left lower quadrant and an enlarged uterus consistent with 8 weeks of gestation are also indicative of an ectopic pregnancy.
Actions to Take
- Perform ultrasound: To confirm the diagnosis and locate the ectopic pregnancy.
- Administer IV fluids: To stabilize the client and prepare for potential surgical intervention.
Parameters to Monitor
- Vaginal bleeding: To assess the severity and progression of the bleeding.
- Blood pressure: To monitor for signs of internal bleeding or hemodynamic instability.
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