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.
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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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Evaluating the side effects of analgesia is not the priority action in this situation. While it's important to assess for potential
side effects, the client's immediate need to use the bathroom takes precedence.
Analgesia might contribute to urinary retention in some cases, but it's not the most likely reason for the client's request.
Promptly addressing the client's need to void helps prevent bladder distention, discomfort, and potential urinary tract
infections.
Choice B rationale:
Using a wheelchair is not necessary in most cases after a vaginal birth.
Early ambulation is generally encouraged to promote circulation, prevent blood clots, and aid in recovery.
Requiring a wheelchair could delay the client's ability to void and might make her feel less independent.
Choice C rationale:
Advising the client to remain in bed is not recommended practice after a vaginal birth.
Prolonged bed rest can increase the risk of complications, such as blood clots, muscle weakness, and delayed bowel function.
Early ambulation, as tolerated, is crucial for promoting physical recovery and preventing postpartum complications.
Correct Answer is C
Explanation
Choice C rationale:
Endometritis is an inflammation of the inner lining of the uterus (endometrium). It is a common complication after childbirth,
affecting up to 1 in 10 women who deliver vaginally. Symptoms of endometritis typically develop within 1-3 days after
childbirth, but they can sometimes take up to a week to appear.
Swelling in the ankles is a common symptom of endometritis. This is because endometritis can cause inflammation and fluid
buildup in the pelvis, which can put pressure on the veins in the legs and cause them to swell.
Choice A rationale:
An increased heart rate can be a symptom of endometritis, but it is not a specific symptom. An increased heart rate can also be
caused by many other factors, such as fever, dehydration, and anxiety.
Choice B rationale:
Decreased appetite can be a symptom of endometritis, but it is not a specific symptom. Decreased appetite can also be caused
by many other factors, such as pain, fatigue, and nausea.
Choice D rationale:
Dry skin is not a typical symptom of endometritis. Dry skin can be caused by many other factors, such as dehydration,
medications, and underlying medical conditions.
Therefore, the most likely manifestation of endometritis in this patient is swelling in the ankles.
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