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?.
Evaluate the firmness of the uterus (fundus).
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
No explanation
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Washing the cord daily with mild soap and water is not recommended as it can delay healing and increase the risk of infection.
Choice B rationale:
Applying petroleum jelly to the cord stump is not recommended as it can create a moist environment that promotes bacterial growth.
Choice C rationale:
The diaper should be folded down to keep the cord stump dry and exposed to air, which promotes healing.
Choice D rationale:
Giving a sponge bath until the cord stump falls off is recommended to keep the area dry and prevent infection.
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