A woman is brought to the labor and delivery unit after delivering a full term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first?
Perform a fundal massage.
Draw blood for hemoglobin and hematocrit.
Obtain a complete obstetrical history.
Inspect the perineum for lacerations.
The Correct Answer is A
Choice A: Performing a fundal massage is the first priority in this situation to assess and manage uterine tone and prevent postpartum hemorrhage.
Choice B: Drawing blood for hemoglobin and hematocrit can be important but is not the immediate priority when the client has just delivered outside the hospital.
Choice C: Obtaining a complete obstetrical history is important but can be done after addressing the immediate postpartum concerns.
Choice D: Inspecting the perineum for lacerations is also important but should be done after addressing uterine tone and hemorrhage prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Obliterating the entry and inserting the correct information may make the charting less clear and may not be considered a best practice in documentation.
Choice B: Drawing one line through the entry and inserting the correct information is a common method for correcting errors in paper documentation. It maintains clarity while indicating that an error was made and corrected.
Choice C: Charting the correct information in the next column may lead to confusion and does not clearly indicate that an error was made and corrected.
Choice D: Notifying the charge nurse that the entry needs to be revised may be necessary in some situations but is not the first step in correcting a charting error. The error should be corrected at the point of documentation.
Correct Answer is B
Explanation
Choice A: A platelet count of 135,000/mm3 is slightly below the lower end of the normal range, but it may not be considered critically low. It is not the highest priority finding among the choices provided.
Choice B: A blood urea nitrogen (BUN) level of 75 mg/dL is significantly elevated and outside the normal range. Elevated BUN can indicate kidney dysfunction or dehydration and should be reported promptly.
Choice C: Decreased deep tendon reflexes may be related to various factors, including medication effects, and may not be considered the highest priority finding unless it is associated with other concerning symptoms.
Choice D: Periodic nausea and vomiting can be common side effects of chemotherapy, but they may not be considered the highest priority finding unless they are severe, persistent, or associated with signs of dehydration or electrolyte imbalances.
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