After delivery of the placenta, a client's uterus is slow to contract.

Which of the following is a priority nursing intervention?

Measure blood pressure hourly.

Prepare to administer blood products as prescribed.

Administer intravenous fluids.

Initiate oxytocin infusion as prescribed.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Measuring blood pressure hourly is an important part of monitoring a postpartum client, but it is not the priority. While vital signs are crucial, the immediate physiological threat is ongoing hemorrhage from uterine atony, which must be addressed directly to prevent shock.

Choice B rationale

Preparing to administer blood products may become necessary if the client experiences significant blood loss, but it is not the initial priority. The first intervention is to stop or reduce the bleeding by promoting uterine contraction, which will minimize the need for subsequent blood transfusions.

Choice C rationale

Administering intravenous fluids is a supportive measure to maintain circulatory volume, but it does not address the underlying cause of the hemorrhage. The priority is to stimulate uterine contractions to compress the myometrial arteries and prevent further blood loss.

Choice D rationale

Initiating an oxytocin infusion is the priority nursing intervention. Oxytocin is a potent uterotonic agent that stimulates uterine contractions, causing the myometrium to clamp down on blood vessels at the placental site, thereby reducing postpartum hemorrhage.

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Correct Answer is C

Explanation

Choice A rationale

Throwing away all stuffed animals is an unnecessary and extreme measure. The lice and nits are unlikely to survive for an extended period off the host. Sealing the items in an airtight bag for a specific duration is a more cost-effective and practical method to ensure any lice or nits are suffocated and die, preventing re-infestation.

Choice B rationale

Changing bed linen every 12 hours is not scientifically necessary. Lice and nits can survive for a limited time off the scalp, but not long enough to warrant such frequent changes. Changing and washing bedding and clothing in hot water and drying them on high heat once a day for a few days is sufficient to kill any lice or nits that may have fallen off.

Choice C rationale

Sealing all non-washable items in airtight bags for two weeks is a highly effective method. Lice and nits require a human host for survival, feeding on blood. Without a host, they will die from starvation within one to two weeks. Sealing items suffocates any remaining lice and ensures that any nits that may hatch will also die without a food source.

Choice D rationale

Soaking all hair items in alcohol is not a standard or recommended practice. While alcohol can be a disinfectant, it is not the primary method for treating lice and may damage the items. Combing with a fine-toothed nit comb, washing in hot water, or sealing items are more proven and safer methods for eradicating lice from personal belongings and preventing re-infestation.

A. Encourage the client to ambulate. B. Instruct the client to press inward on their abdomen periodically. C. Urge the client to cough and take deep breaths. D. Urge the client not to dislodge the IV fluid line.

Correct Answer is A

Explanation

Choice A rationale

Ambulation is the most effective intervention for preventing thromboembolism. Movement of the lower extremities promotes venous return and blood flow, preventing venous stasis, which is the primary predisposing factor for clot formation. Encouraging the client to get out of bed and walk as soon as medically stable after a cesarean birth reduces the risk of deep vein thrombosis and subsequent pulmonary embolism by a significant margin.

Choice B rationale

Instructing the client to press inward on their abdomen periodically is not an intervention for thromboembolism prevention. This action may cause discomfort and does not promote blood flow in the lower extremities. It is not a scientifically supported method for preventing venous stasis or clot formation in the legs, which are the main concerns for thromboembolism in this population.

Choice C rationale

Urging the client to cough and take deep breaths is an intervention to prevent respiratory complications like atelectasis and pneumonia. While important for post-operative care, this action does not directly address the risk of thromboembolism in the lower extremities. The mechanism of clot formation is related to venous stasis, which is best addressed by movement and not by respiratory exercises.

Choice D rationale

Urging the client not to dislodge the IV fluid line is an important general safety measure to ensure proper hydration and medication administration. However, it is not an intervention specifically aimed at preventing thromboembolism. The risk of thromboembolism is a circulatory issue related to venous stasis, and this action does not impact blood flow or clot formation in the veins. .

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