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
Methylergonovine is a medication used to prevent postpartum hemorrhage. It works by causing the uterus to contract, which helps to control bleeding and expel any remaining placental fragments.
Choice B rationale
While infection control is important in the postpartum period, methylergonovine is not specifically used to prevent postpartum infection.
Choice C rationale
Methylergonovine does not prevent hypertension. In fact, it can cause hypertension as a side effect.
Choice D rationale
Methylergonovine is not used to prevent thromboembolic events. Its primary use is to prevent and control postpartum hemorrhage.
Correct Answer is B
Explanation
Choice A rationale
While a pattern of contractions can be a sign of labor, it is not the definitive sign of true labor. Contractions may also occur in false labor, also known as Braxton Hicks contractions. These contractions do not lead to changes in the cervix.
Choice B rationale
Changes in the cervix, including effacement (thinning) and dilation (opening), are the definitive signs of true labor. During true labor, contractions lead to progressive changes in the cervix, which allow for the baby to be born.
Choice C rationale
Rupture of the membranes, or “water breaking,” can occur in both true labor and false labor. Therefore, it is not the definitive sign of true labor.
Choice D rationale
The station of the presenting part refers to the position of the baby’s head (or other presenting part) in relation to the mother’s pelvis. While the station can change during labor as the baby descends into the pelvis, it is not the definitive sign of true labor.
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