A nurse is caring for a client who is 1 hr postpartum.
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.
Select the 6 actions the nurse should take.
Firmly massage the uterine fundus.
Provide emotional support.
Administer oxygen.
Weigh the perineal pads.
Insert indwelling urinary catheter.
Administer methylergonovine.
Administer terbutaline.
Correct Answer : A,B,C,D,E,F
A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss.
D: Correct. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
E: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively.
F: Correct. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
G: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. The nurse should avoid including raw fruits in the client's diet because they can harbor bacteria and fungi that can cause infection in a client who has neutropenia, which is a low white blood cell count.
B. Incorrect. The nurse should limit visits from anyone who is sick or has been exposed to an infection, but there is no need to restrict visits from young children specifically, as long as they are healthy and follow proper hand hygiene.
C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated, because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
Correct Answer is B, A, D, C
Explanation
B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.
A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.
D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.
C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.
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