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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.

A. Apply oxygen at 2 L/min via nasal cannula. B. Massage the client’s fundus. C. Turn the client to a side-lying position. D. Assist the client to empty their bladder.

Correct Answer is C

Explanation

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula may be beneficial for a client experiencing hypotension following the administration of epidural anesthesia, but it is not the primary action a nurse should take.
Choice B rationale
Massaging the client’s fundus is not an appropriate action for a nurse to take when a client is hypotensive following the administration of epidural anesthesia.
Choice C rationale
Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
Choice D rationale
Assisting the client to empty their bladder may be beneficial in certain circumstances, but it is not the primary action a nurse should take when a client is hypotensive following the administration of epidural anesthesia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

“A nurse is assessing a patient who is 3 days postpartum. Which of the following findings should the nurse report to the provider?”

Correct Answer is B

Explanation

A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

Correct Answer is C

Explanation

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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?