A nurse is caring for a female client on the postpartum unit.

Based on the 0800 assessment, the nurse should

and
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Complete the sentence: The nurse should massage the uterus and prepare to administer oxytocin.

Rationale for correct answers:
Uterine atony is the most common cause of postpartum hemorrhage (PPH), indicated by a boggy uterus and heavy bleeding with clots. Uterine massage stimulates uterine contractions, promoting involution and reducing bleeding. Oxytocin is a first-line uterotonic agent that increases uterine tone by stimulating smooth muscle contraction, helping to control hemorrhage. Normal hemoglobin is 11-16 g/dL; the client’s drop to 9.4 g/dL and hematocrit decrease to 27% (normal 33%-47%) indicate blood loss requiring prompt intervention.

Rationale for incorrect Response 1 options:
Inserting an indwelling urinary catheter is unnecessary here because the client emptied her bladder without difficulty, and urinary retention is not evident. Oxygen administration by nasal cannula is not indicated since the client’s respiratory rate is normal and there is no sign of hypoxia. Immediate oxygen is reserved for hypoxic or unstable patients.

Rationale for incorrect Response 2 options:
Administering oxygen by nasal cannula is not needed without hypoxia signs. Initiating a 1000 mL sodium chloride bolus might be considered later if hypovolemia or hypotension worsens but is not the immediate priority. Inserting an indwelling urinary catheter is not indicated as the bladder is emptying normally, and unnecessary catheterization risks infection.

Take-home points:

Postpartum hemorrhage is primarily caused by uterine atony, presenting with a boggy uterus and heavy bleeding.
Prompt uterine massage and administration of oxytocin are critical first-line interventions to control bleeding.
Laboratory values such as hemoglobin and hematocrit help assess blood loss severity and guide management.
Differentiation from other causes of bleeding (e.g., retained placenta, lacerations) requires assessment but initial treatment focuses on uterine tone restoration.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

A positive pregnancy test detects the presence of human chorionic gonadotropin (hCG) in urine or blood. While highly suggestive, it is classified as a probable sign because certain conditions other than pregnancy can elevate hCG levels, although these are rare, making it not definitively diagnostic.

Choice B rationale

Amenorrhea, the cessation of menstruation, is a common early indicator of pregnancy due to hormonal changes, specifically rising progesterone levels that inhibit follicular development and uterine shedding. However, various factors unrelated to pregnancy, such as stress or hormonal imbalances, can also cause amenorrhea, categorizing it as a presumptive sign.

Choice C rationale

Fetal heart sounds, when auscultated, are a definitive sign of pregnancy because they directly confirm the presence of a viable fetus. This auditory confirmation is unambiguous and cannot be attributed to any other condition, making it a positive sign of pregnancy.

Choice D rationale

Chadwick sign refers to the bluish-purple discoloration of the cervix, vagina, and labia due to increased vascularity and blood flow, typically observed around 6-8 weeks of gestation. While highly indicative of pregnancy, it is considered a probable sign because other conditions can also cause pelvic congestion, although less commonly.

A. I should see my provider in 2 weeks for a second dose of the immunization. B. I will need to prevent getting pregnant for 4 months after I receive the immunization. C. I will need an additional rubella immunization during the first trimester with my next pregnancy. D. I can breastfeed my baby even though I received this immunization.

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

Explanation

Choice A rationale

A single dose of the rubella vaccine is typically sufficient to confer immunity. A second dose is not routinely recommended after postpartum administration. The primary goal is to prevent congenital rubella syndrome in future pregnancies by ensuring the mother develops adequate antibody titers to the virus.

Choice B rationale

The rubella vaccine contains live attenuated virus, which carries a theoretical risk of congenital rubella syndrome if the vaccine virus crosses the placenta during pregnancy. Therefore, clients are advised to avoid conception for at least 1 to 3 months, commonly stated as 4 months, after vaccination to minimize any potential fetal exposure.

Choice C rationale

The rubella immunization typically provides long-lasting immunity. It is not necessary to receive an additional rubella immunization during the first trimester of a subsequent pregnancy. Antibody titers are usually maintained, protecting against future rubella infection and subsequent fetal harm.

Choice D rationale

The rubella vaccine is considered safe for breastfeeding mothers and their infants. The live attenuated virus is not shed in breast milk in significant amounts that would pose a risk of infection to the infant. Therefore, breastfeeding can continue without interruption after rubella immunization.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a female client on the postpartum unit. Based on the 0800 assessment, the nurse should ________ and ________.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization. Which of the following statements by the client indicates an understanding of the teaching?

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

Explanation

A nurse is teaching a class to clients who are pregnant. Which of the following topics should the nurse include in the discussion about cesarean birth? (Select all that apply.)

A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take?

A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. Complete the following sentence by using the list of options. The nurse should identify that ____________ and ___________ are findings that require follow-up.

A nurse is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (Select all that apply.)

A nurse is caring for an adolescent client who is at 24 weeks of gestation. The client's prepregnancy weight was within the recommended range for their height and they have gained 2.7 kg (6 lb) during the pregnancy. Which of the following statements should the nurse make?

A nurse is preparing to administer an opioid analgesic to a client who is in active labor. Which of the following assessments should the nurse perform?

A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a female client on the postpartum unit.

Based on the 0800 assessment, the nurse should

and
.