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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are associated with umbilical cord compression, not placenta previa. In placenta previa, the placenta covers the cervical os, but it does not typically cause variable decelerations on fetal monitoring.
Choice B rationale
Painless vaginal bleeding is a hallmark sign of placenta previa. This occurs because the placenta is located near or over the cervical os, leading to bleeding when the cervix dilates or effaces.
Choice C rationale
A rigid abdomen is more indicative of placental abruption, where the placenta detaches prematurely from the uterine wall, causing pain and a tense abdomen, not typically seen in placenta previa.
Choice D rationale
Uterine tachysystole is characterized by excessive uterine contractions and is not a clinical finding related to placenta previa. Tachysystole often results from excessive oxytocin use or other uterine stimulants.
Correct Answer is B
Explanation
Choice A rationale
Meconium stools are common in newborns and not a concern in the context of weight loss.
Choice B rationale
Depressed fontanels can indicate dehydration in a newborn, which is critical, especially with significant weight loss.
Choice C rationale
Rust-stained urine is often due to urate crystals and is typical in newborns, not specifically alarming.
Choice D rationale
Overlapping suture lines can be a normal finding in a newborn's head and not indicative of an acute problem relating to weight loss.
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