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.

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

Explanation

Choice A rationale

Tachycardia is a common finding in hyperemesis gravidarum due to fluid volume deficit. Significant and persistent vomiting leads to hypovolemia, which triggers a compensatory increase in heart rate to maintain cardiac output and tissue perfusion. The body attempts to compensate for reduced circulating blood volume by increasing the rate at which blood is pumped.

Choice B rationale

Dry mucous membranes are a direct clinical sign of dehydration, which is a hallmark of hyperemesis gravidarum. Prolonged and severe vomiting leads to significant fluid loss, depleting the body's water content. This desiccation is visibly manifested in the oral cavity as dry and sticky mucous membranes, indicating intracellular and extracellular fluid deficit.

Choice C rationale

Poor skin turgor, characterized by skin that remains tented when pinched, is another objective indicator of dehydration. The loss of interstitial fluid due to excessive vomiting reduces the elasticity and plumpness of the skin. This finding reflects a significant depletion of fluid volume within the subcutaneous tissues.

Choice D rationale

Polyuria, meaning excessive urination, is not a typical finding in hyperemesis gravidarum. Instead, severe vomiting and dehydration would lead to oliguria (decreased urine output) as the kidneys attempt to conserve fluid to compensate for the significant fluid losses. The body's priority is fluid retention.

Choice E rationale

Hypertension is generally not associated with hyperemesis gravidarum. Due to significant fluid loss and dehydration, clients with hyperemesis gravidarum are more likely to experience orthostatic hypotension or even profound hypotension as a result of hypovolemia. The decreased circulating blood volume leads to reduced vascular resistance and blood pressure.

A. A newborn who has a respiratory rate of 34/min. B. A newborn who has acrocyanosis. C. A newborn who has caput succedaneum. D. A newborn who has an axillary temperature of 36° C (96.8° F).

Correct Answer is D

Explanation

Choice A rationale

A respiratory rate of 34 breaths/min for a newborn is within the normal physiological range, which is typically 30 to 60 breaths/min. This finding does not indicate an immediate respiratory compromise or distress, and thus, this newborn does not require the most urgent assessment compared to others.

Choice B rationale

Acrocyanosis, which is the bluish discoloration of the hands and feet, is a common and usually benign finding in newborns during the first 24 to 48 hours after birth. It is due to immature peripheral circulation and does not indicate an emergency, therefore not requiring the nurse's first assessment.

Choice C rationale

Caput succedaneum is a localized swelling on the newborn's scalp that can cross suture lines, resulting from pressure during birth. While it is a notable finding, it is generally benign and resolves spontaneously within a few days, not indicating an immediate life-threatening condition requiring the first assessment.

Choice D rationale

An axillary temperature of 36° C (96.8° F) is below the normal range for a newborn, which is typically 36.5° C to 37.5° C (96.8° F to 99.5° F). Hypothermia in newborns can lead to significant metabolic demands, increased oxygen consumption, and potential for cold stress, making this newborn the priority for immediate assessment and intervention.

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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

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

Explanation

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Correct Answer is D

Explanation

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

Based on the 0800 assessment, the nurse should

and
.