A nurse is evaluating the effectiveness of oxytocin infusion for a client who has postpartum hemorrhage.
Which of the following findings indicates that the medication is working?
The uterine fundus is firm and at the level of the umbilicus
The lochia flow is moderate and bright red
The blood pressure is 90/60 mm Hg and pulse is 110/min
The urine output is 25 mL/hr and specific gravity is 1.030
The Correct Answer is A
This indicates that the uterus has contracted well and the bleeding has stopped. Oxytocin is a drug that helps the uterus to contract and prevent postpartum hemorrhage (PPH), which is excessive bleeding after childbirth.
Choice B is wrong because the lochia flow should be moderate and dark red, not bright red. Bright red blood suggests active bleeding and possible PPH.
Choice C is wrong because the blood pressure is low and the pulse is high, which are signs of shock due to blood loss. PPH can cause a dangerous drop in blood pressure and lead to shock or death.
Choice D is wrong because the urine output is low and the specific gravity is high, which are signs of dehydration due to blood loss. PPH can cause fluid imbalance and kidney damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Massaging the uterine fundus gently is the first action that the nurse should take to stimulate uterine contractions and control bleeding due to uterine atony.Uterine atony is the most common cause of postpartum hemorrhage and occurs when the uterus fails to contract after delivery.
Choice A is wrong because administering oxytocin as prescribed is a secondary action that can be taken after massaging the uterine fundus if bleeding persists.Oxytocin is a medication that promotes uterine contraction and reduces blood loss.
Choice C is wrong because starting an intravenous line with a large bore catheter is a tertiary action that can be taken after massaging the uterine fundus and administering oxytocin if bleeding continues.An intravenous line can provide fluid replacement and blood transfusion if needed.
Choice D is wrong because placing the client in a side lying position is not a priority action for postpartum hemorrhage due to uterine atony.This position may help reduce pressure on the vena cava and improve blood flow, but it does not address the underlying cause of bleeding.
Correct Answer is A
Explanation
Methylergonovine is a medication that stimulates uterine contractions and helps prevent or treat postpartum hemorrhage due to uterine atony or retained placental fragments.However, it can also cause an increase in blood pressure, so the nurse should monitor the client’s blood pressure before and after giving the medication.
Choice B. Temperature is wrong because methylergonovine does not affect the client’s temperature.
Choice C. Respiratory rate is wrong because methylergonovine does not affect the client’s respiratory rate.
Choice D. Oxygen saturation is wrong because methylergonovine does not affect the client’s oxygen saturation.
Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressures respectively.
Normal ranges for temperature are 36.5°C to 37.5°C or 97.7°F to 99.5°F.
Normal ranges for respiratory rate are 12 to 20 breaths per minute.Normal ranges for oxygen saturation are 95% to 100%.
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