A nurse is caring for a client who is 2 hours postpartum.
The client has an IV infusion of lactated Ringer’s with 25 units of oxytocin and large lochia rubra.
Vital signs include blood pressure 146/81, pulse 80/min, and respirations 18/min.
Which of the following actions should the nurse clarify with the provider?

Administer oxygen by non-rebreather mask at 5 L/min.

Administer methylergonovine 0.2 mg IM now.

Insert a urinary catheter.

Increase the infusion rate of the IV fluid.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Oxygen administration is not indicated in this situation. The client's vital signs are stable, and there is no evidence of

respiratory distress.

Oxygen administration could potentially mask signs of postpartum hemorrhage, which is a serious complication.

It is important to assess the client's respiratory status closely, but oxygen should not be administered unless there is a clear

indication for it.

Choice B rationale:

Methylergonovine is a medication that is used to treat postpartum hemorrhage.

It works by contracting the uterus and reducing blood flow.

However, it is a potent medication that can have serious side effects, such as hypertension and seizures.

It is important to clarify the order with the provider before administering this medication.

The provider may want to assess the client further or consider other options before ordering methylergonovine.

Choice C rationale:

Inserting a urinary catheter is not necessary in this situation.

The client is not experiencing any urinary problems, and there is no evidence of bladder distention.

Catheterization can increase the risk of urinary tract infection, so it should only be performed when there is a clear indication

for it.

Choice D rationale:

Increasing the infusion rate of the IV fluid may be helpful in some cases of postpartum hemorrhage.

However, it is important to assess the client's fluid status before increasing the infusion rate.

Too much fluid can lead to pulmonary edema, which is a serious complication.

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Correct Answer is D

Explanation

Choice A rationale:

Assisting the client to ambulate is not the immediate action required in this scenario. The nurse has found a small amount of

lochia rubra on the client’s perineal pad, and the fundus is midline and firm at the umbilicus. These are normal findings for a

client who is 4 hours postpartum. However, the nurse should ensure that there is no excessive bleeding, which could be a sign

of postpartum hemorrhage.

Choice B rationale:

Performing a fundal massage is not necessary in this case. Fundal massage is usually performed when the uterus is boggy or

soft, which could indicate uterine atony, a leading cause of postpartum hemorrhage. In this scenario, the fundus is firm and at

the level of the umbilicus, which is a normal finding 4 hours postpartum.

Choice C rationale:

Increasing the rate of IV fluids is not the immediate action required in this scenario. IV fluids are usually increased to expand

intravascular volume in cases of postpartum hemorrhage. In this case, the nurse has found a small amount of lochia rubra on

the client’s perineal pad, which is a normal finding 4 hours postpartum.

Choice D rationale:

Checking for blood under the client’s buttocks is the correct action for the nurse to take in this scenario. This is to ensure that

there is no excessive bleeding, which could be hidden under the client’s buttocks. Excessive bleeding could be a sign of

postpartum hemorrhage, a potentially life-threatening complication.

A. Fundal consistency B. Urinary output C. Blood pressure D. Heart rate

Correct Answer is A

Explanation

Choice A rationale:

Oxytocin is a hormone that causes the uterus to contract. It is often given to women after childbirth to help the uterus return

to its normal size and to prevent heavy bleeding. Therefore, monitoring the consistency of the fundus (the upper part of the

uterus) is an effective way to evaluate the effectiveness of this medication.

Choice B rationale:

While urinary output is an important vital sign to monitor in all patients, it is not directly related to the effectiveness of

Oxytocin. Oxytocin does not have a significant effect on urinary output.

Choice C rationale:

Blood pressure is another vital sign that should be monitored in all patients. However, it is not the primary indicator of

Oxytocin’s effectiveness. While Oxytocin can cause blood pressure changes, these are usually transient and not the primary

intended effect of the medication.

Choice D rationale:

Heart rate, like blood pressure and urinary output, is an important vital sign to monitor in all patients. However, it is not the

primary indicator of Oxytocin’s effectiveness. Oxytocin does not have a significant direct effect on heart rate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 4 hours postpartum.The nurse finds a small amount of lochia rubra on the client's perineal pad, and the fundus is midline and firm at the umbilicus.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is receiving Oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate the effectiveness of this medication?

Correct Answer is A

Explanation

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia.Which of the following responses should the nurse make?

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A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

A nurse is collecting data from a client who is 24 hours postpartum. Which of the following findings should the nurse expect?

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