A nurse is caring for a client.
Which of the following interventions should the nurse perform? (Click on the exhibit tabs for additional information about the client.
There are three tabs that contain separate categories of data.)

Inspect the perineum.

Massage the fundus.

Administer oxytocin.

Assist the client to void.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Inspecting the perineum does not address uterine atony, which is the leading cause of postpartum hemorrhage. Interventions should focus on uterine contraction to minimize bleeding.

Choice B rationale

Massaging the fundus stimulates uterine contractions, reducing uterine atony and preventing further hemorrhage. This is a first-line intervention for postpartum excessive bleeding.

Choice C rationale

Administering oxytocin enhances uterine contractions and is effective in managing hemorrhage. However, fundal massage is prioritized initially to assess uterine tone and response.

Choice D rationale

Assisting the client to void helps empty the bladder, which may improve uterine contraction. However, fundal massage is the most immediate measure to prevent further bleeding.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Handwashing before breastfeeding minimizes the risk of pathogen transmission, protecting both the mother and infant. This practice is critical for managing mastitis, which can be complicated by infection.

Choice B rationale

Proper latching techniques reduce nipple trauma, aiding in the prevention of further mastitis development. Correct latching also facilitates effective milk drainage, minimizing milk stasis and associated risks.

Choice C rationale

Alternating breastfeeding with formula feeding reduces milk removal, increasing the risk of milk stasis and infection. Breastfeeding exclusively, if tolerated, is vital for resolving mastitis and maintaining milk supply.

Choice D rationale

Allowing nipples to air dry promotes healing of any nipple trauma. Moist environments facilitate bacterial growth, complicating mastitis recovery. Air drying reduces infection risk and improves comfort.

A. Abruptio placentae. B. Hydatidiform mole. C. Preterm labor. D. Placenta previa.

Correct Answer is A

Explanation

Choice A rationale

Abruptio placentae involves premature placental separation, linked to cocaine use, which increases vasoconstriction and hypertension. Symptoms include pain, vaginal bleeding, and fetal distress due to impaired placental function.

Choice B rationale

Hydatidiform mole causes abnormal trophoblastic growth with no association with cocaine use. Signs include significantly elevated HCG and uterine enlargement unrelated to gestational age.

Choice C rationale

Preterm labor may follow substance use but lacks the hallmark signs of pain and bleeding characteristic of abruptio placentae. Preterm labor focuses on uterine contractions and cervical changes.

Choice D rationale

Placenta previa presents with painless vaginal bleeding and no abdominal pain. Cocaine use does not heighten placenta previa risk directly but may cause other obstetric complications.

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A nurse is caring for a client.Which of the following interventions should the nurse perform? (Click on the exhibit tabs for additional information about the client.There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is breastfeeding and has mastitis.Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding.The client has a history of cocaine use.The nurse should identify that the client is likely experiencing which of the following complications?

Correct Answer is A

Explanation

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A nurse is caring for a client.
Which of the following interventions should the nurse perform? (Click on the exhibit tabs for additional information about the client.
There are three tabs that contain separate categories of data.)