A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

Prepare to administer a prescribed oxytocic preparation.

Assess the bladder for distention.

Massage the client's fundus.

Assess the client's blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Administering a prescribed oxytocic preparation is an important step in managing postpartum hemorrhage, as it helps to contract the uterus and reduce bleeding. However, it is not the first action a nurse should take when a client has saturated a perineal pad within 10 minutes postpartum.

Choice B reason:
Assessing the bladder for distention is also important because a full bladder can impede the contraction of the uterus and lead to increased bleeding. However, this is not the immediate action to take in the event of excessive postpartum bleeding.

Choice C reason:
Massaging the client's fundus is the first action the nurse should take. A boggy uterus, which is soft and not well contracted, can lead to excessive bleeding. Fundal massage stimulates the uterus to contract and can quickly reduce blood loss.

Choice D reason:
Assessing the client's blood pressure is vital to determine the client's hemodynamic status, but it is not the first action to take. The priority is to address the cause of the bleeding and stabilize the client.

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Correct Answer is B

Explanation

Choice A reason:
Magnesium sulfate is used in the management of severe preeclampsia primarily for seizure prophylaxis. One of the key side effects of magnesium sulfate is its impact on neuromuscular transmission, leading to diminished deep-tendon reflexes as serum magnesium levels rise. The therapeutic range for anticonvulsant prophylaxis is typically between 5-8 mg/dL. Reflexes may begin to diminish when serum levels reach 8-12 mg/dL, indicating potential magnesium toxicity. Therefore, diminished reflexes are a warning sign to reassess the infusion rate and possibly reduce or discontinue the medication.

Choice B reason:
A respiratory rate of 16 breaths per minute falls within the normal adult range and suggests that the client's respiratory system is not being adversely affected by the magnesium sulfate infusion. Respiratory rate is a critical parameter to monitor during magnesium sulfate therapy, as respiratory depression is a serious side effect of magnesium toxicity. Maintaining a normal respiratory rate indicates that it is safe to continue the infusion at the current rate.

Choice C reason:
While a urine output of 50 mL/hr is on the lower end of the normal range, it is still considered adequate for most adults. In the setting of magnesium sulfate therapy for severe preeclampsia, maintaining adequate urine output is essential for ensuring that the kidneys can excrete the magnesium to prevent accumulation and toxicity. If urine output decreases significantly, it may necessitate reevaluation of the infusion rate or additional interventions to support renal function.

Choice D reason:
A heart rate of 56 beats per minute is slightly bradycardic but may not be clinically significant if the client is asymptomatic. However, magnesium has a direct effect on cardiac function, and high levels can lead to bradycardia and other cardiac conduction abnormalities. It is important to monitor the client's heart rate and rhythm during magnesium sulfate therapy to detect any early signs of cardiac involvement due to magnesium toxicity.

A. Measured blood glucose of 96 mg/dL. B. Enhanced production of estrogen. C. Heart rate of 120 bpm. D. Weakened respiratory contractions.

Correct Answer is C

Explanation

Choice A reason:
A blood glucose level of 96 mg/dL is within the normal range for a fasting blood sugar level in pregnancy, which is typically between 70 to 95 mg/dL. It is crucial to monitor blood glucose levels during pregnancy due to the risk of gestational diabetes, which can have adverse effects on both the mother and the fetus.

Choice B reason:
The production of estrogen is indeed enhanced during pregnancy. Estrogen plays a vital role in maintaining the pregnancy, promoting fetal development, and preparing the body for childbirth. Elevated levels of estrogen are expected and contribute to many of the physiological changes experienced during pregnancy.

Choice C reason:
A heart rate of 120 bpm (beats per minute) can be considered slightly elevated during pregnancy. The normal resting heart rate for a pregnant woman is usually between 60 to 100 bpm. However, during pregnancy, the heart rate can increase to accommodate the increased blood volume and the needs of the growing fetus. Given the information provided, the most likely scenario that the nurse should address is the heart rate of 120 bpm, as it is slightly above the normal range and may need monitoring or intervention.

Choice D reason:
Weakened respiratory contractions are not typically expected during pregnancy. Pregnant women may experience shortness of breath due to the growing uterus pushing against the diaphragm, but the respiratory contractions themselves should not be weakened. If this occurs, it may warrant further investigation.

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A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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