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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
Flexing the knee while resting does not typically alleviate the symptoms of a possible DVT15161718.
Choice B rationale
Applying cold compresses is not typically recommended for the symptoms of a possible DVT15161718.
Choice C rationale
Massaging the area is not recommended, especially if the patient is showing signs of a possible DVT, as it could dislodge a clot.

Choice D rationale
Elevating the leg can help reduce swelling and improve blood flow, which can help alleviate pain associated with a possible DVT15161718.

A. Deep tendon reflexes of +1. B. 3+ protein in the urine. C. Blood pressure 148/98 mm Hg. D. 1+ pitting sacral edema.

Correct Answer is A

Explanation

Choice A rationale
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is often associated with hyperreflexia, which would be a deep tendon reflex of +3 or +467.
Choice B rationale
3+ protein in the urine is consistent with preeclampsia. Proteinuria is a common finding in preeclampsia due to kidney involvement.
Choice C rationale
Blood pressure 148/98 mm Hg is consistent with preeclampsia. Hypertension is a key feature of preeclampsia.
Choice D rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the face and hands, is a common finding in preeclampsia.

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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?

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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?