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

Explanation

Choice A rationale

Magnesium sulfate toxicity causes central nervous system depression, including respiratory depression. A respiratory rate of 12 breaths/min indicates that the respiratory depression has resolved, suggesting the calcium gluconate, a magnesium antagonist, has effectively reversed the neuromuscular blockade caused by magnesium. A normal respiratory rate is 12-20 breaths/min.

Choice B rationale

Absent deep tendon reflexes (DTRs) are a sign of magnesium sulfate toxicity due to its depressant effect on neuromuscular transmission. If calcium gluconate were effective, DTRs would return to normal or become less diminished, indicating resolution of magnesium's inhibitory effects on the nervous system.

Choice C rationale

Slurred speech is a neurological symptom associated with magnesium sulfate toxicity, reflecting central nervous system depression. If calcium gluconate were effective in reversing the toxicity, slurred speech would improve or resolve as the central nervous system depression diminishes.

Choice D rationale

Urine output of 22 mL/hr indicates oliguria, which can be a sign of worsening preeclampsia or kidney dysfunction, and is not an indicator of effective calcium gluconate administration for magnesium toxicity. Adequate urine output (typically >30 mL/hr) is essential for magnesium excretion and overall renal function.

A. BUN 25 mg/dL (10 to 20 mg/dL). B. Hgb 10.2 mg/dL (11 to 16 mg/dL). C. Fasting blood glucose 70 mg/dL (70 to 110 mg/dL). D. Hct 32% (33 to 47%).

Correct Answer is A

Explanation

Choice A rationale

A BUN level of 25 mg/dL is above the normal range of 10 to 20 mg/dL for pregnant clients. Elevated BUN can indicate impaired renal function, which can be a complication of pregnancy, particularly in conditions like preeclampsia or underlying kidney disease. This finding, especially in a client with a history of anemia, warrants further investigation as it suggests potential kidney compromise affecting waste product excretion.

Choice B rationale

A hemoglobin (Hgb) level of 10.2 mg/dL is slightly below the normal range of 11 to 16 mg/dL for pregnant clients. Given the client's history of anemia, this finding is consistent with their known condition and, while it indicates mild anemia, it might not necessarily represent a new acute prenatal complication requiring immediate report unless there is a significant drop or associated symptoms. Iron supplementation is typically initiated for this level.

Choice C rationale

A fasting blood glucose of 70 mg/dL is within the normal range of 70 to 110 mg/dL. This indicates adequate glucose regulation and does not suggest a prenatal complication such as gestational diabetes. Maintaining a normal fasting blood glucose is a positive indicator for maternal and fetal well-being, especially for a client without a history of diabetes.

Choice D rationale

A hematocrit (Hct) level of 32% is slightly below the normal range of 33 to 47% for pregnant clients. Similar to hemoglobin, a slightly low hematocrit is common in pregnancy due to hemodilution, where plasma volume increases more significantly than red blood cell mass. While it indicates mild physiological anemia, it is often managed with dietary adjustments or iron supplements and does not typically signify an acute prenatal complication requiring immediate report.

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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

A nurse is assessing a client who has preeclampsia and received a dose of calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation and has a history of anemia. Which of the following results should the nurse identify and report as an indication of a prenatal complication?

Correct Answer is A

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
.