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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Correct Answer is B

Explanation

Choice A reason:
The deltoid muscle, while commonly used for IM injections in older children and adults, is not the preferred site for newborns due to their underdeveloped muscle mass in this area. Administering an injection in the deltoid could increase the risk of injury to the surrounding nerves and tissues in newborns.

Choice B reason:
The vastus lateralis muscle is the recommended site for IM injections in newborns. It is the preferred location because it is the largest muscle in the thigh and has sufficient mass to absorb the medication effectively. This muscle is located on the anterolateral aspect of the thigh and is considered the safest site with the least risk of damaging blood vessels, nerves, or bone.

Choice C reason:
The dorsogluteal muscle, located in the buttocks, was once a common site for IM injections. However, it is no longer recommended due to the high risk of injury to the sciatic nerve and significant blood vessels in the area. Additionally, the fat content in the buttocks can affect the absorption of the medication.

Choice D reason:
The ventrogluteal muscle, also located in the hip area, is another site for IM injections but is more suitable for older children and adults. For newborns, the vastus lateralis remains the preferred site due to easier access and less risk of complications.

A. Type 1 diabetes mellitus B. Intrauterine growth restriction C. Hearing loss D. Congenital heart defects

Correct Answer is B

Explanation

Choice A reason:
Type 1 diabetes mellitus is generally not directly associated with maternal smoking. It is an autoimmune condition where the pancreas produces little to no insulin. Risk factors for Type 1 diabetes include family history and possibly environmental factors, but maternal smoking is not a recognized risk factor.

Choice B reason:
Intrauterine growth restriction (IUGR) refers to poor growth of a fetus while in the mother's womb during pregnancy. The causes of IUGR are many, but maternal smoking is a well-documented risk factor. Smoking during pregnancy can reduce oxygen and nutrient delivery to the fetus, leading to low birth weight and other complications.

Choice C reason:
While smoking during pregnancy can increase the risk of various health issues, there is no direct and consistent evidence linking it to hearing loss in newborns. Hearing loss in newborns can be due to genetic factors, infections during pregnancy, or complications at birth.

Choice D reason:
Congenital heart defects are the most common type of birth defect, and their causes can be multifactorial, including genetic and environmental factors. Maternal smoking has been associated with an increased risk of certain congenital heart defects, but the relationship is not as strong as with intrauterine growth restriction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

Correct Answer is B

Explanation

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

Correct Answer is B

Explanation

"How will I know if my baby is getting enough breast milk?"

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 providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who is postpartum and has received methylergonovine. Which of the following findings indicates that the medication was effective?

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse is preparing to administer methylergonovine IM to a client who has experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

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?