A nurse is caring for a client with postpartum hemorrhage.
The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

Assess the client’s pain scale.

Assess the client’s respiratory rate.

Assess the client’s blood pressure.

Assess the client’s last bowel movement.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Assess the client’s blood pressure. Methylergonovine is a uterotonic medication that can cause hypertension and is contraindicated for clients with preeclampsia or cardiac disease.

Therefore, the nurse should check the client’s blood pressure before administering this medication to ensure it is within normal range (120/80 mm Hg or lower).

Choice A is wrong because assessing the client’s pain scale is not a priority assessment before giving methylergonovine.

Pain is not a contraindication for this medication and does not affect its effectiveness.

Choice B is wrong because assessing the client’s respiratory rate is not a priority assessment before giving methylergonovine.

Respiratory rate is not affected by this medication and does not indicate any adverse effects.

Choice D is wrong because assessing the client’s last bowel movement is not a priority assessment before giving methylergonovine.

Bowel movement is not related to postpartum hemorrhage or uterine atony, which are the indications for this medication.

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Correct Answer is B

Explanation

The correct answer is choice B. Position the patient in a left lateral position.This is because late fetal decelerations indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus.By positioning the patient on her left side, the blood flow to the placenta and the fetus is improved.

Choice A is wrong because notifying the health care provider is not the first action that the nurse should take.The nurse should first intervene to correct the cause of fetal distress and then inform the provider.

Choice C is wrong because increasing the patient’s intravenous rate may not help with uteroplacental insufficiency.It may also cause fluid overload or pulmonary edema in the patient.

Choice D is wrong because providing the patient with oxygen via a face mask is not the most effective way to increase fetal oxygenation.Oxygen therapy may be used as an adjunct to other interventions, but it is not sufficient by itself.

A. Rubella immunization should be given in the early postpartum period. B. Gamma globulin should be given when the client is admitted in labor. C. Gamma globulin should be given at next visit. D. Rubella immunization should be given at next visit.

Correct Answer is A

Explanation

Rubella immunization should be given in the early postpartum period.This is because rubella infection during pregnancy can cause serious birth defects or miscarriage, and rubella vaccine is contraindicated during pregnancy.Therefore, the best time to vaccinate a woman who is not immune to rubella is after she delivers her baby.

Choice B is wrong because gamma globulin is not effective for preventing rubella infection or congenital rubella syndrome (CRS).Gamma globulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not induce lasting immunity.

Choice C is wrong because gamma globulin should not be given at the next visit for the same reason as choice B.Moreover, gamma globulin can interfere with the response to live vaccines such as rubella vaccine, so it should not be given within 3 months before or after vaccination.

Choice D is wrong because rubella immunization should not be given at the next visit or during pregnancy, as it can pose a risk to the fetus.Rubella vaccine is a live attenuated virus vaccine that can cross the placenta and infect the fetus.The risk of CRS from vaccination during pregnancy is low, but it cannot be ruled out completely.Therefore, women who receive rubella vaccine should avoid pregnancy for at least 4 weeks after vaccination.

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A nurse is caring for a client with postpartum hemorrhage. The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

Nursing Test Bank

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A nurse is caring for a client with postpartum hemorrhage.
The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?