A nurse is caring for a female client on the postpartum unit.
Based on the 0800 assessment, the nurse should
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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.
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