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 ["A","B","D","E"]

Explanation

Choice A rationale:

Performing hand hygiene before and after voiding is crucial in preventing perineal infection. Hand hygiene is the most

effective way to prevent the spread of infections, including those that can infect the perineum.

Choice B rationale:

Cleaning the perineal area from front to back is a standard recommendation to prevent infection. This method ensures that

bacteria from the anal area are not spread to the vagina and urethra, which can cause urinary tract infections.

Choice C rationale:

Sitting on an inflatable donut is not typically recommended for the prevention of perineal infection. While it can provide

comfort for those with perineal pain, especially after childbirth, it does not directly contribute to the prevention of infection.

Choice D rationale:

Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, especially after a

vaginal birth. While it does not directly prevent infection, it can promote healing and comfort, which can indirectly help

prevent infection.

Choice E rationale:

Blotting the perineal area dry after voiding is another important step in preventing perineal infection. Keeping the area dry

prevents the growth of bacteria and other microbes that thrive in moist environments.

A. The client is experiencing preterm labor. B. The nurse should administer prescribed medication and encourage bed rest. C. The nurse should monitor contraction frequency and fetal heart rate.

Correct Answer is C

Explanation

Choice C rationale:

Monitoring contraction frequency is essential to assess the progression of labor. Contractions are the tightening and relaxing of the uterine muscles that help to dilate the cervix and push the baby down the birth canal. The frequency of contractions is measured in minutes from the beginning of one contraction to the beginning of the next. As labor progresses, contractions become more frequent, regular, and intense. Monitoring contraction frequency helps the nurse to determine the stage of labor, assess the effectiveness of interventions, and identify any potential complications.

Monitoring fetal heart rate is crucial to assess the well-being of the baby during labor. The fetal heart rate is normally between 110 and 160 beats per minute. A normal fetal heart rate indicates that the baby is getting enough oxygen and is not in distress. Variations in the fetal heart rate, such as decelerations or tachycardia, can indicate potential problems and may require intervention.

Choice A rationale:

Preterm labor is defined as labor that begins before 37 weeks of gestation. The client in this scenario is at 38 weeks of gestation, which is considered term. Therefore, preterm labor is not the most likely condition.

Choice B rationale:

The administration of medication and bed rest may be appropriate interventions for preterm labor, but they are not the most appropriate interventions for a client in labor at 38 weeks of gestation. At this stage of pregnancy, labor is considered to be full-term, and interventions are focused on supporting the normal labor process and ensuring the safety of the mother and baby.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["A","B","D","E"]

Explanation

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?

Correct Answer is C

Explanation

Choice C rationale:

Choice A rationale:

Choice B rationale:

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 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?

A nurse is performing an assessment on a postpartum patient. The uterus is found to be displaced to the right.Which of the following actions should the nurse take?

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 collecting data from a client who is 3 days postpartum and is breastfeeding. Her lochia rubra is moderate, and her breasts feel hard and warm.Which of the following recommendations should the nurse give the client?

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

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?