A nurse is caring for a client who is 1 hr 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.
Anticipate a prescription for misoprostol.
Obtain a specimen for a Kleihauer-Betke test.
Administer betamethasone IM.
The Correct Answer is B
Rationale:
A. Avoiding sterile vaginal examinations is not the appropriate action for managing uterine atony and postpartum hemorrhage. Vaginal examinations may be necessary to assess the degree of cervical dilation and to identify potential causes of bleeding.
B. Anticipating a prescription for misoprostol is appropriate for managing uterine atony and postpartum hemorrhage. Misoprostol is a prostaglandin analog that helps to promote uterine contractions and control bleeding.
C. Obtaining a specimen for a Kleihauer-Betke test is not the priority action in this situation. The Kleihauer-Betke test is used to estimate the amount of fetal-maternal hemorrhage in Rh-negative mothers.
D. Administering betamethasone IM is not indicated for the management of uterine atony and postpartum hemorrhage. Betamethasone is a corticosteroid used to promote fetal lung maturity when preterm birth is anticipated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Bathing the baby immediately after a feeding is not recommended, as it may cause discomfort or spit-up due to movement and manipulation of the baby's body. It's best to wait until the baby is settled and not hungry.
B. Putting a soft mattress in the baby's crib increases the risk of sudden infant death syndrome (SIDS). Firm mattresses are recommended to reduce the risk of suffocation.
C. Washing the baby's face with plain water is a safe and appropriate instruction. Using plain water helps prevent irritation or allergic reactions that may occur with soaps or other cleansing agents.
D. Placing a bumper pad in the baby's crib is not recommended due to the risk of suffocation and strangulation. Bumper pads can also increase the risk of SIDS.
Correct Answer is C
Explanation
Rationale:
A. An apneic episode less than 15 seconds may be considered within normal limits for a newborn and does not necessarily indicate a decline in status.
B. Fine crackles may indicate fluid in the lungs but are not specific to a decline in the newborn's status.
C. An oxygen saturation of 89% indicates hypoxemia, which is a significant concern and suggests respiratory compromise. It indicates a decline in the newborn's status and requires immediate intervention to improve oxygenation.
D. Nasal flaring is a sign of respiratory distress but may not be as concerning as a low oxygen saturation level in this context. It indicates increased work of breathing but does not provide direct information about oxygenation status.
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