A nurse is caring for a client who is postpartum and received methylergonovine (methergine). Which of the following findings indicates that the medication was effective?
Report of absent breast pain
Increase in lochia
Increase in blood pressure
Fundus firm to palpation
The Correct Answer is D
Choice A) Report of absent breast pain is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client does not have mastitis or engorgement. Mastitis is an infection of the breast tissue that causes pain, swelling, redness, and fever. Engorgement is a condition where the breasts become overfilled with milk, causing pain, hardness, and leakage. Both conditions are common in postpartum women who are breastfeeding, but they are not related to methylergonovine or uterine bleeding. Therefore, this response is irrelevant and inaccurate.
Choice B) Increase in lochia is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the medication was ineffective or that the client has a complication. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the uterus after childbirth. It usually lasts for about 4 to 6 weeks and gradually decreases in amount and color. Methylergonovine is a medication that helps to control uterine bleeding by improving the tone and contractions of the uterus. An increase in lochia may mean that methylergonovine did not work well or that the client has a problem such as retained placenta, infection, or subinvolution. Therefore, this response is opposite and inaccurate.
Choice C) Increase in blood pressure is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client has a side effect or a risk factor. Blood pressure is the force of blood against the walls of the arteries. It is measured by two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure when the heart rests). The normal range for blood pressure is 120/80 mm Hg or lower. Methylergonovine is a medication that can cause vasoconstriction, which means narrowing of the blood vessels and increasing of the blood pressure. This can lead to complications such as hypertension, stroke, or heart attack. Therefore, this response is adverse and inaccurate.
Choice D) Fundus firm to palpation is correct because this is a finding that indicates that the medication was effective and that the client has a good outcome. The fundus is the upper part of the uterus that can be felt through the abdomen after childbirth. It should be firm, midline, and at or below the level of the navel. A firm fundus means that the uterus has contracted well and stopped bleeding. Methylergonovine is a medication that helps to achieve this by improving the tone and contractions of the uterus. Therefore, this response is positive and accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A) Weight gain of 0.5 kg during the past 2 weeks: This is a normal weight gain for a pregnant woman and does not indicate preeclampsia.
Choice B) Pitting pedal edema at the end of the day: This is a common symptom of pregnancy and does not necessarily indicate preeclampsia. It can be relieved by elevating the legs and wearing compression stockings.
Choice C) Blood pressure increase to 138/86 mm Hg: This is a mild elevation of blood pressure and does not meet the criteria for preeclampsia, which is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least four hours apart.
Choice D) Dipstick value of 3+ for protein in her urine: This is a sign of significant proteinuria, which is one of the main features of preeclampsia. Proteinuria is defined as a urinary protein excretion of 300 mg or more in 24 hours or a dipstick reading of 1+ or higher. A dipstick value of 3+ indicates severe proteinuria and requires immediate attention and treatment. This woman has the highest risk of developing complications from preeclampsia, such as eclampsia, HELLP syndrome, placental abruption, or fetal growth restriction . Therefore, she should be seen by the nurse first.
Correct Answer is C
Explanation
Choice a) Have the parent fold the infant's arms across the chest is incorrect because this is not a helpful way to calm a preterm infant. Folding the arms across the chest can restrict the infant's breathing and movement, and may increase their stress and discomfort. Preterm infants need gentle and supportive touch, not restraint or pressure.
Choice b) Encourage the parent to place the infant back in the warmer is incorrect because this is not a necessary or beneficial action for a preterm infant who is showing signs of overstimulation. Placing the infant back in the warmer can interrupt the bonding and attachment process between the parent and the infant, and may make the infant feel more isolated and insecure. Preterm infants need close and frequent contact with their parents, not separation or detachment.
Choice c) Encourage the parent to do kangaroo care is correct because this is an effective and evidence-based method of soothing and stabilizing a preterm infant who is experiencing overstimulation. Kangaroo care is a technique where the parent holds the infant skin-to-skin on their chest, providing warmth, comfort, and security. Kangaroo care can reduce the infant's stress hormones, lower their heart rate and blood pressure, improve their oxygenation and breathing, enhance their growth and development, and strengthen their bond with their parent.
Choice d) Cover the infant with a warm bed blanket is incorrect because this is not a sufficient or optimal way to comfort a preterm infant who is displaying signs of overstimulation. Covering the infant with a warm bed blanket can provide some warmth and protection, but it does not offer the same benefits as kangaroo care. A warm bed blanket cannot mimic the parent's heartbeat, voice, smell, and movement, which are essential for the infant's emotional and physiological well-being. Preterm infants need human touch and interaction, not just physical warmth.
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