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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hypotension, or low blood pressure, is a common complication from an epidural block16. This occurs because the medication used in the epidural can block sympathetic nerve fibers, which can cause blood vessels to dilate and lead to a drop in blood pressure16.
Choice B rationale
Vomiting is not typically a direct complication of an epidural block16. Nausea and vomiting during labor can have many causes, including the physical process of labor, pain, and medications.
Choice C rationale
Tachycardia, or a fast heart rate, is not typically a complication of an epidural block16. In fact, some of the medications used in an epidural can actually cause a slower heart rate.
Choice D rationale
While severe respiratory depression can occur with an epidural, it is extremely rare16. More commonly, an epidural can cause a feeling of breathlessness or difficulty taking a deep breath, but it should not cause significant respiratory depression.
Correct Answer is C
Explanation
Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.
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