A nurse is caring for a patient who is 1 hour postpartum and has uterine atony. The patient is exhibiting a large amount of vaginal bleeding.What action should the nurse take?
Obtain a specimen for a Kleihauer-Betke test.
Anticipate a prescription for misoprostol.
Administer betamethasone IM.
Avoid performing sterile vaginal examinations.
The Correct Answer is B
Choice A rationale
Obtaining a specimen for a Kleihauer-Betke test is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
Choice B rationale
Misoprostol is a medication that can be used to treat uterine atony. It helps to contract the uterus and reduce bleeding.
Choice C rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication often used to mature the lungs of a fetus at risk of premature birth, not to treat uterine atony.
Choice D rationale
Avoiding sterile vaginal examinations is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.4°C (99.3°F) is within the normal range and does not indicate endometritis.
Choice B rationale
Scant lochia is not typically associated with endometritis. In fact, women with endometritis may experience heavy lochia or foul-smelling lochia.
Choice C rationale
A WBC count of 9,000/mm is within the normal range and does not indicate endometritis.
Choice D rationale
Uterine tenderness is a common symptom of endometritis. Other symptoms can include fever, malaise, and foul-smelling lochia.
Correct Answer is B
Explanation
Choice A rationale
While assessing the client’s kidney function is important in general, it is not the best way to evaluate medication adherence. Kidney function can affect the metabolism and excretion of medications, but it does not directly indicate whether the client is taking their medication as prescribed.
Choice B rationale
Correct answer. Checking the client’s serum medication level is the most direct and reliable way to evaluate medication adherence. If the client is taking the medication as prescribed, the serum medication level should be within the therapeutic range.
Choice C rationale
Determining the client’s apical pulse rate can provide information about the client’s overall cardiovascular status and can indicate certain drug effects or side effects, but it does not directly measure medication adherence.
Choice D rationale
Asking the client if they are taking the medication as prescribed can provide useful information, but it relies on self-report, which may not be reliable. Some clients might forget doses or not take the medication exactly as prescribed.
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