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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An ectopic pregnancy, where the fertilized egg attaches outside the uterus, often presents with unilateral, cramp-like abdominal pain. This is because as the fertilized egg grows in an area where it cannot survive, it can cause irritation and bleeding, leading to pain. This pain is often one-sided or unilateral and can vary from mild to severe. It’s one of the key symptoms that can suggest an ectopic pregnancy in the early weeks of gestation.
Choice B rationale
Severe nausea and vomiting are not typically the primary symptoms associated with an ectopic pregnancy. While nausea can be a symptom of early pregnancy, severe nausea and vomiting alone without other symptoms would not necessarily indicate an ectopic pregnancy.
Choice C rationale
Uterine enlargement greater than expected for gestational age is not a symptom of an ectopic pregnancy. In fact, because the pregnancy is not in the uterus, the size of the uterus may not correlate with the expected size at the given gestational age.
Choice D rationale
While vaginal bleeding can occur in an ectopic pregnancy, it is not typically a large amount. The bleeding is often lighter than normal menstrual bleeding and may be associated with a change in color of the vaginal discharge.
Correct Answer is C
Explanation
Choice A rationale
While itching can be a side effect of opioid analgesics, it is not the priority observation. Itching can be uncomfortable for the client, but it is not life-threatening.
Choice B rationale
A temperature of 38.2°C (100.8°F) indicates a low-grade fever. While this should be monitored, it is not the priority observation in this situation.
Choice C rationale
The priority observation is the client’s blood pressure. Opioid epidural analgesia can cause hypotension, which can lead to inadequate perfusion to the mother and the fetus. Therefore, the nurse should prioritize monitoring the client’s blood pressure.
Choice D rationale
Weakness of the lower extremities can be a side effect of epidural analgesia, but it is not the priority observation. The nurse should monitor for this, but it is not as critical as monitoring the client’s blood pressure.
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