A nurse is caring for a client who gave birth 2 hours ago.
The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?
Administer oxytocin infusion.
Evaluate the firmness of the uterus.
Initiate oxygen therapy by non-rebreather mask.
Obtain a type and crossmatch.
The Correct Answer is B
Choice A rationale
Administering oxytocin infusion is usually done to stimulate uterine contractions and prevent postpartum hemorrhage. However, it’s not the first action to take when the client’s blood pressure is low.
Choice B rationale
Evaluating the firmness of the uterus is crucial in this situation. A soft or “boggy” uterus could indicate uterine atony, a condition that can lead to serious postpartum hemorrhage. This could be the cause of the client’s low blood pressure.
Choice C rationale
Initiating oxygen therapy by non-rebreather mask can help increase the client’s oxygen saturation levels, but it doesn’t address the underlying cause of the low blood pressure.
Choice D rationale
Obtaining a type and crossmatch is important if the client needs a blood transfusion. However, it’s not the first action to take. The nurse should first assess for possible causes of the low blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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Correct Answer is D
Explanation
Choice A rationale
Thrombophlebitis is a condition where a blood clot in a vein causes inflammation and pain. While it can occur postpartum, it is not directly related to the weight of the newborn.
Choice B rationale
Retained placental fragments can occur after childbirth and can lead to postpartum hemorrhage or infection. However, this complication is not directly related to the weight of the newborn.
Choice C rationale
Puerperal infection, also known as postpartum infection, can occur after childbirth. However, it is not directly related to the weight of the newborn.
Choice D rationale
Uterine atony, a condition where the uterus fails to contract after the delivery of the baby, is a common cause of postpartum hemorrhage. A larger newborn, such as one weighing 9 lb 6 oz, can overstretch the uterus, increasing the risk of uterine atony.
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