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 B

Explanation

Choice A rationale:

The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus

(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and

descend into the pelvic cavity, guided by the process known as involution.

Choice B rationale:

A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common

as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of

postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized

by high blood pressure and signs of damage to another organ system, often the kidneys.

Choice C rationale:

A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a

slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.

Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.

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 collecting data from a postpartum client. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is B

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 reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is collecting data from a client who is 12 hours postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?

A nurse is caring for a client who is 12 hours postpartum.The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

A nurse is caring for a group of clients on a postpartum unit. Which of the following findings should be reported to the RN immediately?

A nurse is assisting in the care of a client who is at 38 weeks of gestation.What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor.Which of the following actions should the nurse take?

A nurse is collecting data from a patient who gave birth one week ago.Which of the following findings should the nurse identify as a manifestation of endometritis?

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?