A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?
Massage the client's fundus.
Insert an indwelling urinary catheter.
Administer oxygen at 10 L/min
Elevate the client's right hip
The Correct Answer is A
A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.
B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.
C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.
D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Hct 39.6 is incorrect. This hemoglobin level is within a typical range and may not require immediate intervention.
Choice B Reason:
Serum albumin 4.5 g/dL is incorrect. A serum albumin level of 4.5 g/dL is within the normal range and does not suggest an urgent issue.
Choice C Reason:
WBC 9,000/mm³ is incorrect. A white blood cell count of 9,000/mm³ is within the normal range and is not typically a cause for immediate concern in the absence of other symptoms or indications.
Choice D Reason:
Platelets 50,000/mm³ is correct. A platelet count of 50,000/mm³ is significantly below the normal range and may indicate thrombocytopenia, a condition associated with preeclampsi
A. Thrombocytopenia in preeclampsia can lead to bleeding complications and requires close monitoring and management.
Correct Answer is B
Explanation
The correct answer is B. The client will experience a successful induction of labor.
A. The Bishop score is a pre-induction assessment that evaluates several factors, including cervical dilation, effacement, consistency, position, and fetal station. It is used to predict the likelihood of a successful induction of labor. A high Bishop score indicates favorable conditions for induction.
B. Correct. A higher Bishop score indicates a more favorable cervix for induction, and the chances of a successful induction of labor are increased.
C. Lower back pain during labor is not specifically associated with the Bishop score. It can be a common complaint during labor, but it is not predicted by the Bishop score.
D. Dinoprostone is a prostaglandin used for cervical ripening. If the Bishop score indicates an unfavorable cervix, dinoprostone or other cervical ripening agents may be considered to prepare the cervix for induction.
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