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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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage. One of the symptoms can be hyperreflexia, or overly active reflexes, not diminished reflexes.
Choice B rationale
Blood pressure of 148/98 mm Hg is consistent with preeclampsia, as one of the defining features of preeclampsia is high blood pressure.
Choice C rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, or swelling, is a common symptom of preeclampsia.
Choice D rationale
3+ protein in the urine is consistent with preeclampsia. One of the defining features of preeclampsia is the presence of excess protein in urine (proteinuria), which indicates kidney problems. Deep vein thrombosis Deep vein thrombosis Explore
Correct Answer is D
Explanation
Choice A rationale
Postpartum depression is characterized by severe mood swings, crying too much, difficulty bonding with the baby, withdrawing from family and friends, loss of appetite or eating much more than usual, inability to sleep or sleeping too much, overwhelming tiredness or loss of energy. While some of these symptoms overlap with the ones mentioned in the question, postpartum depression is usually more severe and lasts longer.
Choice B rationale
The letting-go phase is the final phase of maternal adjustment during which the mother moves forward from her existing role to take on a new one as a parent. This phase is characterized by reestablishment of relationships with others, resumption of sexual intimacy, resolution of physical symptoms, and attainment of a new normal. The symptoms mentioned in the question do not align with this phase.
Choice C rationale
Postpartum psychosis is a rare but serious mental health illness that can affect a woman soon after she has a baby. Symptoms can include hallucinations, delusions, a manic mood, a low mood, loss of inhibitions, restlessness, and severe confusion. The symptoms mentioned in the question do not align with this condition.
Choice D rationale
This is the correct answer. Postpartum fatigue is characterized by extreme tiredness that doesn’t get better with rest or sleep. This fatigue can make it difficult for the new mother to care for herself and her baby. The symptoms mentioned in the question - tearfulness, insomnia, lack of appetite, and a feeling of letdown - are all common symptoms of postpartum fatigue.
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