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 A
Explanation
Choice A rationale
When the fetal head is at 3+ station, it means that the baby’s head has moved down the birth canal and is very close to the vaginal opening. At this stage, the nurse should observe for crowning, which is when the widest part of the baby’s head can be seen at the vaginal opening. This is a critical time during labor, and the nurse needs to be prepared for the delivery of the baby.
Choice B rationale
Applying fundal pressure is not recommended as it can cause complications such as uterine rupture, fetal distress, and maternal discomfort. It is also not necessary when the fetal head is at 3+ station as the baby is already moving down the birth canal.
Choice C rationale
Oxytocin is a hormone that can stimulate uterine contractions. However, it is not necessary to prepare to administer oxytocin when the fetal head is at 3+ station. At this stage, the mother’s body is already effectively progressing through labor.
Choice D rationale
Observing for the presence of a nuchal cord, which is when the umbilical cord is wrapped around the baby’s neck, is important throughout labor. However, it is not the primary action the nurse should take when the fetal head is at 3+ station.
Correct Answer is C
Explanation
Choice A rationale
Assessing her skin for hydration and color can provide some information about the client’s overall health and nutritional status, but it doesn’t directly assess her diet.
Choice B rationale
Assessing a list she makes describing a good diet can provide information about the client’s knowledge of nutrition, but it doesn’t provide information about her actual dietary intake.
Choice C rationale
Asking her to describe her intake for the last week can provide a more accurate picture of her actual dietary habits and nutritional status.
Choice D rationale
Asking her to describe her total intake for a week during pregnancy can provide information about her dietary habits during pregnancy, but it doesn’t assess her current diet.
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