Methylergonovine is prescribed for a client to treat postpartum hemorrhage caused by uterine atony.
Prior to the nurse administering the medication, what assessment is the priority?
Amount of blood loss.
The blood pressure.
The level of consciousness.
The uterine tone.
The Correct Answer is B
Choice A rationale
While the amount of blood loss is critical for determining the severity of the hemorrhage and the need for immediate treatment, it is not the priority assessment before administering methylergonovine. The amount of blood loss determines the need for the drug, but the blood pressure determines its safety before administration. Methylergonovine is a potent vasoconstrictor and must be used cautiously in clients with elevated blood pressure to prevent hypertensive crisis or stroke.
Choice B rationale
Methylergonovine is an ergot alkaloid that acts as a potent vasoconstrictor and uterine stimulant. Its primary side effect and contraindication are hypertension and preeclampsia. Because the drug dramatically increases systemic vascular resistance, it can cause a sudden, severe elevation in blood pressure. Therefore, checking the blood pressure is the priority assessment to ensure the client's pressure is within safe limits before administration, preventing potential complications like stroke.
Choice C rationale
Although a change in the level of consciousness (LOC) could indicate hypovolemic shock from severe blood loss or a hypertensive emergency, it is a secondary finding. The primary, direct, and modifiable risk associated with methylergonovine administration is its potential to cause acute, severe hypertension. Checking the client's baseline blood pressure (Choice B) is the specific, essential safety check before administering this vasoconstrictive medication.
Choice D rationale
The uterine tone or atony is the indication for the medication; the client is already diagnosed with uterine atony (flaccid uterus) causing the hemorrhage. The medication's purpose is to contract the uterus (increase tone). The priority before administration, however, is to assess the client for contraindications or serious adverse reaction risks. The potent vasoconstrictive effect on peripheral arteries makes blood pressure (Choice B) the most critical pre-administration safety assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale
Abruptio placentae is the premature separation of the placenta from the uterine wall. The classic signs include dark red vaginal bleeding (due to the pooling of blood behind the placenta), constant and intense abdominal pain, and a rigid, hypertonic uterus that does not relax between contractions. This rigidity is caused by the hemorrhage, clots, and resulting irritation and sustained contraction of the myometrium.
Choice A rationale
Preterm labor is characterized by regular uterine contractions causing cervical changes before 37 weeks' gestation. While contractions cause pain, the uterus typically relaxes completely between them, and the bleeding, if present, is usually bright red and less profuse than that seen with abruptio placentae, and it does not cause sustained uterine firmness.
Choice B rationale
Placenta previa is the implantation of the placenta over or near the cervical os. Its hallmark sign is painless, bright red vaginal bleeding that often occurs late in the second or third trimester. The uterus remains soft and relaxed, unlike the hard, board-like abdomen found with a severe placental abruption.
Choice D rationale
Placenta accreta involves abnormal adherence of the placenta to the uterine wall, typically becoming symptomatic at delivery when the placenta fails to separate. While it can cause bleeding, it does not typically present with the acute, severe abdominal pain and the sustained, board-like uterine rigidity seen before delivery, as it is a pathology of adherence, not separation.
Correct Answer is D
Explanation
Choice A rationale
Placing a rolled towel under the client's knees is generally discouraged because it can promote venous stasis in the lower extremities by compressing the popliteal vein, thereby increasing the risk of developing a deep vein thrombosis (DVT). While comfort measures are important, this specific action is not a critical immediate action necessary for safety or to advance care upon admission to the labor unit.
Choice B rationale
The healthcare provider must be notified of the client's admission and status, but this is not the most critical immediate action for the nurse. The immediate priority upon admission is to complete the initial assessment, which includes establishing the fetal heart rate (FHR) baseline (which is currently being monitored) and assessing the stage of labor through a sterile vaginal exam, then notifying the provider with complete findings.
Choice C rationale
Administering supplemental oxygen via a non-rebreather mask (NRB) is indicated for signs of maternal hypoxemia (low oxygen saturation) or for fetal distress. Although the client has an increased respiratory and cardiac rate, her lungs are clear, and she is alert, suggesting anxiety or labor pain is the likely cause. Oxygen is not immediately required without evidence of true hypoxemia.
Choice D rationale
Performing a sterile vaginal exam (SVE) to assess cervical dilation and effacement is a critical, immediate action upon admission to the labor unit to determine the stage of labor. This information is essential for triage, ongoing management, and planning. It provides the baseline data needed to compare against subsequent exams and to communicate the client's status effectively to the healthcare provider.
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