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 lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min, which of the following actions should the nurse take next?

Insert an indwelling urinary catheter.

Administer oxytocin by continuous IV infusion.

Massage the client's fundus to promote contractions.

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

Answer and Explanation

The Correct Answer is C

Choice A reason:
Inserting an indwelling urinary catheter can be helpful in measuring urine output and reducing bladder distention, which may impede uterine contractions. However, it is not the immediate next step in managing postpartum hemorrhage.

Choice B reason:
Administering oxytocin by continuous IV infusion is a standard intervention to promote uterine contractions after delivery, which helps to control bleeding. However, before starting an oxytocin infusion, it is important to ensure that there are no retained placental fragments and that the uterus is not already well-contracted.

Choice C reason:
Massaging the client's fundus is the priority action because it can stimulate uterine contractions, which are essential for controlling postpartum bleeding. A firm, contracted uterus helps to compress the blood vessels and prevent excessive bleeding.

Choice D reason:
Tilting the client onto her right side with her legs elevated can help improve venous return and may be part of the management for shock. However, the immediate concern in a postpartum client with excessive bleeding is to manage the bleeding by promoting uterine contractions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.

Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.

Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.

Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.

A. Observe for meconium in respiratory secretions. B. Monitor for hyperglycemia. C. Monitor for hyperthermia. D. Identify manifestations of anemia.

Correct Answer is A

Explanation

Choice a reason:
Observing for meconium in respiratory secretions is crucial for SGA newborns because they are at increased risk for meconium aspiration syndrome (MAS). MAS occurs when a newborn breathes in meconium-stained amniotic fluid into their lungs, which can cause respiratory distress. It is more common in full-term or post-term babies, and early detection and treatment are vital for improving outcomes.

Choice b reason:
Monitoring for hyperglycemia is important as SGA newborns are at risk for blood sugar imbalances. Hyperglycemia in newborns can be due to various factors, including stress, and requires careful management to prevent complications. However, it is not the primary concern immediately post-delivery for SGA newborns compared to the risk of MAS.

Choice c reason:
Monitoring for hyperthermia is less commonly a primary concern for SGA newborns immediately after birth. Hyperthermia can lead to dehydration and increase metabolic demands, which can be harmful to newborns. However, the immediate risk of hyperthermia is not as high as the risk of MAS for SGA newborns.

Choice d reason:
Identifying manifestations of anemia is important in newborn care. Anemia in newborns can present as pale skin, irritability, and a fast heart rate. While it is a condition that requires attention, the immediate post-delivery concern for SGA newborns is typically the risk of MAS rather than anemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

Correct Answer is A

Explanation

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?