A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client’s blood pressure is 60/50 mm Hg. What is the first action the nurse should take?
Evaluate the firmness of the uterus.
Oxygenate by rebreather mask.
Administer oxytocin infusion.
Obtain a type and crossmatch.
The Correct Answer is A
Choice A rationale
Evaluating the firmness of the uterus is the first action the nurse should take when a client’s blood pressure is 60/50 mm Hg after giving birth. A soft or “boggy” uterus can indicate uterine atony, a condition in which the uterus fails to contract after birth. Uterine atony can lead to significant postpartum hemorrhage, which can cause hypotension.
Choice B rationale
Oxygenating by rebreather mask may be necessary if the client shows signs of hypoxia or difficulty breathing, but it is not the first action the nurse should take.
Choice C rationale
Administering oxytocin infusion can stimulate uterine contractions and help control postpartum bleeding. However, the nurse should first assess the firmness of the uterus.
Choice D rationale
Obtaining a type and crossmatch may be necessary if the client needs a blood transfusion, but it is not the first action the nurse should take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Cervical dilation is a key sign that labor has begun. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a physical change that can be measured during a pelvic exam.
Choice B rationale
Pain above the umbilicus is not typically a sign of labor. During labor, contractions are usually felt as a tightening or cramping in the lower abdomen or back.
Choice C rationale
Brownish vaginal discharge can occur during pregnancy and is not necessarily a sign of labor. If the discharge is heavy, or accompanied by other symptoms such as pain or cramping, it should be evaluated by a healthcare provider.
Choice D rationale
The presence of amniotic fluid in the vaginal vault, also known as “water breaking,” can be a sign that labor is imminent. However, it does not confirm that labor has begun, as it can occur before the onset of contractions and cervical dilation.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
- WBC count: This finding is not consistent with either sickle cell anemia or hemophilia. Both conditions do not typically cause an increase in white blood cell count.
- Temperature: This finding is not consistent with either sickle cell anemia or hemophilia. Neither condition is associated with an elevated body temperature unless there is a concurrent infection.
- Bleeding: This finding is consistent with hemophilia. Hemophilia is a bleeding disorder where the blood does not clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery.
- Reported pain: This finding is consistent with sickle cell anemia. Sickle cell anemia can cause episodes of pain when sickle-shaped red blood cells block blood flow through tiny blood vessels to your chest, abdomen and joints. Pain can also occur in your bones.
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