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 B
Explanation
Choice A rationale
Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.
Choice B rationale
Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.
Choice C rationale
Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.
Choice D rationale
Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Cerebral manifestations such as a mild headache can be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. This should be reported to the provider.
Choice B rationale
Gastrointestinal assessment findings such as heartburn can be common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach. However, severe or persistent heartburn may indicate a more serious condition like gastroesophageal reflux disease (GERD) or preeclampsia. This should be reported to the provider.
Choice C rationale
Respiratory rate alone, without knowing whether it’s increased, decreased, or normal, is not enough information to determine if it should be reported to the provider.
Choice D rationale
Deep tendon reflexes can be hyperactive in clients with preeclampsia. An increase in deep tendon reflexes can be a sign of worsening preeclampsia and should be reported to the provider.
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