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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.

Choice B rationale:

While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

Choice C rationale:

An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.

Choice D rationale:

While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

A. To the right of the umbilicus. B. 2 cm above the umbilicus. C. One fingerbreadth above the symphysis pubis. D. At the level of the umbilicus.

Correct Answer is D

Explanation

The correct answer is choice D. At the level of the umbilicus.

Choice A rationale:

The uterine fundus is not typically found to the right of the umbilicus after delivery.

Choice B rationale:

The uterine fundus is not typically found 2 cm above the umbilicus after delivery.

Choice C rationale:

The uterine fundus is not typically found one fingerbreadth above the symphysis pubis after delivery.

Choice D rationale:

After delivery, the uterine fundus is typically found at the level of the umbilicus.

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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. Which of the following actions should the nurse take first?.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa.The client asks the nurse why the provider does not do an internal examination.Which of the following explanations of the primary reason should the nurse provide?

Correct Answer is A

Explanation

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Correct Answer is D

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. Which of the following actions should the nurse take first?.