A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding.
Which of the following actions should the nurse take?
Avoid performing sterile vaginal examinations
Administer betamethasone IM
Obtain a specimen for a Kleihauer-Betke test
Anticipate a prescription for misoprostol
The Correct Answer is D
Choice A rationale
Avoiding performing sterile vaginal examinations does not directly address the issue of uterine atony and excessive bleeding. While limiting vaginal examinations can reduce the risk of infection, it does not treat uterine atony.
Choice B rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication that is often given to pregnant women who are at risk of preterm birth to help mature the baby’s lungs. It does not treat uterine atony or excessive bleeding.
Choice C rationale
Obtaining a specimen for a Kleihauer-Betke test is not the appropriate action in this situation. The Kleihauer-Betke test is used to detect fetal blood in maternal circulation, which is not relevant in this case.
Choice D rationale
Anticipating a prescription for misoprostol is the correct action. Misoprostol is a medication that can be used to treat uterine atony by causing the uterus to contract, which can help control postpartum bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Contractions feeling further apart is not a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice B rationale
Feeling relief from pelvic pressure may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice C rationale
Improvement in back labor is a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice D rationale
Lessening of suprapubic pain may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Correct Answer is B
Explanation
Choice A rationale
The Plastibell is not removed 4 hours after the procedure. Instead, it remains on the penis until the foreskin falls off naturally in seven to 10 days.
Choice B rationale
Yellow exudate, which is a normal part of the healing process, will form at the surgical site within 24 hours after a Plastibell circumcision. Parents should be reassured that this is not a sign of infection.
Choice C rationale
The end of the baby’s penis may appear dark red immediately after the procedure, but this should improve within a few days. If the redness persists or worsens, parents should notify the provider.
Choice D rationale
Ensuring that the newborn’s diaper is snug is not specific to the Plastibell circumcision technique. While a snug diaper can help prevent leaks, it should not be so tight as to cause discomfort or restrict circulation.
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