A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?
Tilt the client onto her right side with her legs elevated to at least 30°.
Administer oxytocin by continuous IV infusion.
Insert an indwelling urinary catheter.
Massage the client's fundus to promote contractions.
The Correct Answer is D
A. Tilting the client onto her right side with her legs elevated does not directly address the underlying cause of postpartum hemorrhage.
B. Oxytocin is a uterotonic medication commonly used to help control and prevent PPH by promoting uterine contractions, which can help to compress blood vessels and reduce bleeding. However, it is not the priority action.
C. Inserting an indwelling urinary catheter may be necessary to monitor urine output and empty the bladder but is not a priority.
D. Massaging the client's fundus to promote contractions is a standard intervention and initial action for managing PPH
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A fetal heart rate of 158/min is within the normal range for a fetus.
B. Respirations of 16/min are within the normal range for an adult.
C. Headache can be a symptom of pre-eclampsia, but it does not necessarily indicate magnesium toxicity.
D. Decreased urinary output can indicate renal insufficiency or impaired kidney function, which can be a sign of magnesium toxicity.
Correct Answer is A
Explanation
Methylergonovine is a medication commonly used to prevent or treat postpartum hemorrhage, which is excessive bleeding after childbirth. It works by causing uterine contractions, which help to control bleeding by compressing blood vessels in the uterus. It is often administered following vaginal delivery to reduce the risk of excessive bleeding and complications associated with postpartum hemorrhage.
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