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.

Answer and Explanation

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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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Infective endocarditis is an infection of the inner lining of the heart’s chambers or valves. It’s typically caused by bacteria entering the blood and settling in the heart. It is considered an acquired heart disease because it develops during a person’s lifetime.
Choice B rationale
Kawasaki disease is an illness that causes inflammation in arteries, veins, and capillaries. It’s most common in children younger than 5 years old. While it’s not a heart disease, it can lead to serious heart problems if not treated.
Choice C rationale
Hypoplastic left heart syndrome is a type of congenital heart defect, meaning it’s present at birth. Therefore, it’s not considered an acquired heart disease.
Choice D rationale
Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. It can be acquired or inherited.
Choice E rationale
Transposition of the great vessels is a serious but rare heart defect present at birth (congenital), in which the two main arteries leaving the heart are reversed (transposed). Therefore, it’s not considered an acquired heart disease.

A. Practice Kegel exercises. B. Do abdominal crunches. C. Perform sit-ups. D. Engage in pelvic tilt exercises.

Correct Answer is A

Explanation

Choice A rationale
Practicing Kegel exercises is a common recommendation for postpartum women experiencing urinary incontinence. Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum. Strengthening these muscles can help control urinary incontinence.
Choice B rationale
Abdominal crunches are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice C rationale
Similar to abdominal crunches, sit-ups are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice D rationale
While pelvic tilt exercises can be beneficial for postpartum women, they are not specifically targeted at improving urinary incontinence.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following heart diseases are considered acquired? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is giving discharge instructions to a postpartum client who had a cesarean birth and reports urinary incontinence when sneezing or coughing. What should the nurse recommend?

Correct Answer is A

Explanation

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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?