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. Which of the following actions should the nurse take first?
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
Evaluate the firmness of the uterus.
The Correct Answer is D
Choice A reason: Obtaining a type and crossmatch is not the first action that the nurse should take, as it is a preparatory step for blood transfusion, which may or may not be needed. The nurse should first identify the cause and severity of the hypotension, and initiate immediate interventions to stop the bleeding and restore the circulation.
Choice B reason: Administering oxytocin infusion is not the first action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the uterine tone and bleeding. The nurse should first evaluate the firmness of the uterus and massage it if needed, to stimulate the contraction and retraction of the uterine muscle.
Choice C reason: Initiating oxygen therapy by nonrebreather mask is not the first action that the nurse should take, as it is a supportive intervention that aims to improve the oxygen delivery to the tissues and organs. The nurse should first address the underlying cause of the hypotension, which is most likely postpartum hemorrhage, and prevent further blood loss and shock.
Choice D reason: Evaluating the firmness of the uterus is the first action that the nurse should take, as it can help determine the source and extent of the bleeding, and guide the subsequent interventions. The nurse should palpate the fundus and check the lochia, and report any signs of uterine atony, which is the most common cause of postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as these are the common complications of post-term infants, who are born after 42 weeks of gestation. Meconium aspiration can occur when the fetus passes meconium in utero and inhales it into the lungs, causing respiratory distress, inflammation, and infection. Hypoglycemia can occur due to the depletion of glycogen stores and the increased metabolic demands. Dry, cracked skin can occur due to the loss of vernix caseosa and the reduced amniotic fluid.
Choice B reason: This statement is incorrect, as these are the signs of neonatal hypocalcemia, which is a low level of calcium in the blood. Neonatal hypocalcemia can occur due to maternal diabetes, prematurity, or asphyxia, and can cause jitteriness, seizures, or tetany.
Choice C reason: This statement is incorrect, as these are the characteristics of preterm infants, who are born before 37 weeks of gestation. Excessive vernix caseosa covering the skin is a protective coating that prevents heat and water loss. Lethargy and RDS are signs of immaturity and underdevelopment of the central nervous system and the lungs.
Choice D reason: This statement is incorrect, as these are the features of infants with erythroblastosis fetalis, which is a hemolytic disease caused by the incompatibility of the Rh factor or the ABO blood group between the mother and the fetus. Golden yellow to green-stained skin and nails are due to the accumulation of bilirubin, which is a breakdown product of red blood cells. Absence of scalp hair and an increased amount of subcutaneous fat are due to the chronic hypoxia and edema.
Correct Answer is C
Explanation
Choice A reason: A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions does not need to be reported to the provider immediately, because it may indicate preterm labor, which is not an emergency. The nurse should assess the client's cervix, fetal heart rate, and hydration status, and administer tocolytic therapy as prescribed.
Choice B reason: A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes does not need to be reported to the provider immediately, because they are expected findings in mild preeclampsia. The nurse should monitor the client's blood pressure, urine output, and reflexes, and administer antihypertensive and anticonvulsant medications as prescribed.
Choice C reason: A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache needs to be reported to the provider immediately, because they are signs of severe preeclampsia or impending eclampsia. The nurse should prepare the client for delivery, as it is the only definitive treatment for preeclampsia.
Choice D reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors does not need to be reported to the provider immediately, because they are a common and mild side effect of terbutaline, a beta-adrenergic agonist that relaxes the uterine smooth muscle. The nurse should reassure the client that the tremors are temporary and harmless, and monitor the client's pulse and blood pressure.
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