A nurse is caring for a client who is 2 hours postpartum.
The nurse notes that the client soaked a perineal pad in 10 minutes, the client’s skin color is ashen, and she states she feels weak and light-headed.
After applying oxygen via a non-rebreather face mask at 10 L/min, which of the following actions should the nurse take next?

Tilt the client onto her right side with her legs elevated to at least 30 degrees.

Administer oxytocin by continuous IV infusion.

Insert an indwelling urinary catheter.

Massage the client’s fundus to promote contractions.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Tilt the client onto her right side with her legs elevated to at least 30 degrees. This action is not the most immediate step to take. While it can help improve venous return and thus cardiac output, it does not directly address the issue of postpartum hemorrhage.

Choice B rationale

Administer oxytocin by continuous IV infusion. Oxytocin is a medication that can stimulate uterine contractions and help control postpartum bleeding. However, it should be administered after the nurse has assessed the uterus and determined that it is not contracting effectively on its own.

Choice C rationale

Insert an indwelling urinary catheter. While a full bladder can inhibit effective uterine contractions and contribute to bleeding, inserting a catheter is not the first step in managing a postpartum hemorrhage.

Choice D rationale

Massage the client’s fundus to promote contractions. This is the correct answer. Fundal massage stimulates the uterus to contract, which can help control postpartum bleeding. It is a first-line intervention for a boggy uterus and postpartum hemorrhage.

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Correct Answer is C

Explanation

Choice A rationale

While providing age-appropriate stimulation is important for all newborns, it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.

Choice B rationale

Educating the parents about the defect is an important part of care, but it is not the priority nursing goal. The immediate physical needs of the newborn take precedence.

Choice C rationale

This is the correct answer. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Therefore, maintaining the integrity of the sac is the priority nursing goal.

Choice D rationale

Promoting maternal-infant bonding is important, but it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.

A. Obtain rectal temperatures B. Cover the lesion with a dry dressing C. Apply snug clean diapers D. Place the newborn in the prone position .

Correct Answer is D

Explanation

Choice A rationale

Obtaining rectal temperatures is not recommended for newborns with spinal bifida. This is because the rectal route can introduce bacteria into the body, which can lead to infection.

Additionally, the rectal route may not provide an accurate temperature reading for these newborns.

Choice B rationale

Covering the lesion with a dry dressing is not recommended for newborns with spinal bifida. The lesion should be kept moist to prevent drying and cracking, which can lead to infection.

Choice C rationale

Applying snug clean diapers is not recommended for newborns with spinal bifida. This is because the pressure from the diaper can damage the exposed nerves and tissues in the lesion area.

Choice D rationale

Placing the newborn in the prone position is recommended for newborns with spinal bifida. This position helps to minimize pressure on the lesion and reduces the risk of trauma and infection.

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Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. What should be the nurse’s priority action?

A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)

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A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn’s plan of care?

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A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn’s medical record, which of the following complications should the nurse identify as posing the greatest risk?

A nurse is caring for a client who is in active labor when the client’s membranes rupture. The fetal monitor tracing shows late decelerations. What is the first action the nurse should take?

A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?