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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Strict intake and output monitoring is important in the care of clients with DKA, but it is not the most critical intervention among the choices provided.

Choice B: Maintaining a large bore intravenous (IV) is important for providing the necessary fluids and medications in DKA treatment, but it is not the highest priority.

Choice C: Keeping the client NPO except for ice may be part of the initial management of DKA to address fluid and electrolyte imbalances, but it is not the most important intervention in the client's overall plan of care.

Choice D: Monitoring laboratory values is the most important intervention for a client with diabetic ketoacidosis (DKA). Regular assessment of blood glucose levels, electrolytes (e.g., potassium, sodium), and arterial blood gases (ABGs) is crucial for guiding treatment and ensuring that DKA is resolving. Adjustments to insulin and fluids are based on these laboratory values to prevent complications such as cerebral edema or cardiac arrhythmias.

A. Chicken salad on toast, fruit-flavored yogurt, and iced tea. B. Taco salad, refried beans, low fat ice cream and coffee. C. Bacon. lettuce, and tomato sandwich, grapes, and skim milk D. Canned cream of mushroom soup, tuna salad, and water.

Correct Answer is C

Explanation

Choice A: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.

Choice B: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.

Choice C: Skim milk, grapes, and lettuce are good sources of water that can help dilute the sodium level in the blood. Bacon is a high-sodium food, but it is a small portion compared to the other choices and can be balanced by the rest of the meal.

Choice D: this combination contains higher sodium levels, especially canned soup, so it's not the ideal choice.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is D

Explanation

A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu. Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]

Correct Answer is C

Explanation

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

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