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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Depressed fontanels are not typically associated with increased intracranial pressure (ICP) in infants. In fact, bulging fontanels may be a sign of increased ICP1516.
Choice B rationale
A brisk pupillary reaction to light is not a specific sign of increased ICP in infants. Changes in pupillary reaction can occur in various conditions and are not definitive indicators of increased ICP.
Choice C rationale
Increased sleeping is a symptom of increased ICP in infants. However, this symptom alone is not enough to diagnose increased ICP as it can be seen in other conditions as well.
Choice D rationale
Unspecified symptom is not a valid choice as it does not provide a specific symptom to evaluate.
Correct Answer is B
Explanation
Choice A rationale
While inserting an IV catheter can be a part of the overall management plan for a client showing late decelerations on the electronic fetal monitor, it is not the initial course of action. The primary concern with late decelerations is that they may indicate fetal hypoxia, and the first response should be aimed at improving fetal oxygenation.
Choice B rationale
Assisting the client into the left-lateral position is the correct initial response when late decelerations are observed on the electronic fetal monitor. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.
Choice C rationale
Applying a fetal scalp electrode may be useful for obtaining a more accurate fetal heart rate tracing, but it is not the initial response to late decelerations. The priority is to address the potential fetal hypoxia that late decelerations may indicate.
Choice D rationale
Performing a vaginal exam would not be the initial response to late decelerations. While a vaginal exam can provide valuable information about the progress of labor, it does not address the issue of potential fetal hypoxia indicated by late decelerations.
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