A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?

Evaluate the firmness of the uterus.

Administer oxytocin infusion.

Obtain a type and crossmatch.

Initiate oxygen therapy by nonrebreather mask.

Answer and Explanation

The Correct Answer is A

Choice A rationale

If a nurse notes that a client’s blood pressure is 60/50 mm Hg two hours after giving birth, the first action should be to evaluate the firmness of the uterus. This is because a soft or “boggy” uterus could indicate uterine atony, a condition where the uterus fails to contract after delivery, leading to excessive bleeding and a drop in blood pressure.

Choice B rationale

Administering oxytocin infusion can help stimulate uterine contractions and control postpartum bleeding. However, it is not the first action to take. The nurse should first assess the firmness of the uterus.

Choice C rationale

Obtaining a type and crossmatch is important if a blood transfusion is required. However, this is not the first action. The nurse should first assess the firmness of the uterus.

Choice D rationale

Initiating oxygen therapy can help ensure adequate oxygen supply to the tissues, but it is not the first action. The nurse should first assess the firmness of the uterus.

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Correct Answer is A

Explanation

Choice A rationale

Chorioamnionitis. Based on the information provided, the patient is at risk of developing chorioamnionitis, which is an infection of the membranes surrounding the fetus.

Choice B rationale

Preeclampsia. There is no information provided that would indicate the patient is at risk of developing preeclampsia.

Choice C rationale

Gestational diabetes. There is no information provided that would indicate the patient is at risk of developing gestational diabetes.

Choice D rationale

Preterm labor. There is no information provided that would indicate the patient is at risk of developing preterm labor.

A. The largest fetal diameter has passed through the pelvic outlet. B. The fetal head is in the left occiput posterior position. C. The posterior fontanel is palpable. D. The lowermost portion of the fetus is at the level of the ischial spines.

Correct Answer is D

Explanation

Choice A rationale

The largest fetal diameter passing through the pelvic outlet is not what is indicated by the presenting part being at 0 station. This would be more indicative of a positive station, such as

+31.

Choice B rationale

The position of the fetal head, such as left occiput posterior, is not determined by the station of the presenting part. The station refers to the level of the presenting part in relation to the mother’s ischial spines.

Choice C rationale

The palpability of the posterior fontanel is not related to the station of the presenting part. The fontanels are soft spots on the baby’s head which allow for compression during birth and brain growth after birth.

Choice D rationale

This is the correct interpretation of the clinical finding. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines.

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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 60/50 mm Hg. What should be the nurse’s first action?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient who is in labor. After reviewing the patient’s medical history, vital signs, nurse’s notes, and diagnostic results, which of the following complications should the nurse identify that the patient is at risk of developing?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is D

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. What should be the nurse’s priority action?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

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A nurse is caring for a client who has just delivered a newborn. The nurse notices secretions bubbling out of the newborn’s nose and mouth. Which of the following actions should the nurse prioritize?

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