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","D"]
Explanation
Choice A rationale
The client understanding the importance of monitoring their incision for signs of infection, such as discharge, indicates effective teaching. It is crucial for the client to report any changes to their healthcare provider promptly.
Choice B rationale
Having a fever during the first week at home is not a normal postoperative symptom and could indicate an infection. Therefore, this statement does not indicate effective teaching.
Choice C rationale
Resting in a recliner until the incision is healed is not necessary. While it’s important for the client to rest and recover after surgery, they should also engage in light physical activity, such as walking, to promote circulation and prevent complications such as blood clots.
Choice D rationale
The client should not have unrelieved pain in their abdomen. Persistent pain could indicate a complication, such as an infection or a hematoma. Therefore, this statement indicates effective teaching.
Correct Answer is B
Explanation
Choice A rationale
While the anterior fontanel being soft and level is an important observation in a newborn, it is not typically used as part of a gestational age assessment.
Choice B rationale
The presence of plantar creases covering 3 of the sole is a typical finding in a full-term newborn and is used as part of a gestational age assessment.
Choice C rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is a common finding in newborns, especially shortly after birth. However, it is not typically used as part of a gestational age assessment.
Choice D rationale
Vernix caseosa in the inguinal creases can be a sign of a preterm newborn, as vernix caseosa is typically present in larger amounts in preterm newborns. However, it is not typically used as part of a gestational age assessment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.