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?.

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

The correct answer is choice D. Chronic alcohol use.

Choice A rationale:

Active herpes simplex infection during pregnancy can lead to neonatal herpes, which is a serious condition, but it does not cause the symptoms described.

Choice B rationale:

Chronic cocaine use during pregnancy can lead to premature birth and low birth weight, but it does not typically result in the specific symptoms described.

Choice C rationale:

Folic acid deficiency during pregnancy can lead to neural tube defects, which can cause a range of symptoms, but not the specific ones described.

Choice D rationale:

Chronic alcohol use during pregnancy can lead to Fetal Alcohol Syndrome, which includes slow growth, cognitive and intellectual deficits, and the facial abnormalities described.