While you are taking Monique's vital signs and performing a postpartum assessment 4 hours after delivery, she tells you she is feeling lightheaded.
She has a history of chronic hypertension and obesity.
Her vital signs are blood pressure 85/57 mm Hg, pulse 132, respirations 28, oxygen saturation 94%. Her uterus is boggy at midline, 1 cm above the umbilicus.
What would be your next steps and anticipated orders?
Massage her fundus until firm and ensure IV access. Orders for methylergonovine (Methergine) 0.2 mg IM and an oxytocin bolus.
Massage her fundus until firm and ensure IV access. Orders for carboprost-tromethamine (Hemabate) 250 mcg IM, and an oxytocin bolus.
Gather her peri-pads and chux pads to quantify her blood loss.
Assist her to the restroom to void, then massage her fundus until firm. Inform her that her lightheadedness was from orthostatic hypotension and to be sure to ask for assistance when getting up. There is no change in orders at this time.
Straight catheterize her, then reassess her uterus, massaging it if it's still boggy. Order for oxytocin maintenance at 10 units/1 L of lactated Ringers running at 125 mL/hr.
The Correct Answer is B
Choice A rationale
While massaging the fundus and ensuring IV access are correct initial actions, methylergonovine (Methergine) is typically used for patients without hypertensive history due to its potential to raise blood pressure.
Choice B rationale
This option correctly identifies initial steps and appropriate medication. Carboprost-tromethamine (Hemabate) is effective in controlling postpartum hemorrhage and can be safely used in patients with hypertension when oxytocin is insufficient.
Choice C rationale
Quantifying blood loss is essential but it is not an immediate priority when the patient is showing signs of significant bleeding and instability. Immediate intervention to control bleeding takes precedence.
Choice D rationale
Assisting the patient to the restroom and then massaging the fundus overlooks the immediate need to control bleeding. This approach may delay necessary treatment and increase the risk of further hemorrhage.
Choice E rationale
Straight catheterization and oxytocin maintenance are part of the management of postpartum hemorrhage but do not address the immediate need to ensure uterine contraction and control active bleeding as effectively as the initial steps outlined in Choice B. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Assessing for vaginal bleeding in PPROM is generally not necessary unless there is an indication of placental issues or other complications. PPROM involves the rupture of membranes before 37 weeks, primarily requiring monitoring for infection and fetal wellbeing rather than routine bleeding checks.
Choice B rationale
Monitoring for signs of infection is critical after PPROM because the rupture increases the risk of ascending infections. The nurse should diligently assess for fever, foul-smelling discharge, and other signs of infection to initiate timely interventions, preserving both maternal and fetal health.
Choice C rationale
Checking for cervical dilation in PPROM is important because premature rupture of membranes can lead to preterm labor. Monitoring dilation helps determine if labor is imminent, influencing decisions regarding maternal and neonatal care to prevent complications from premature birth.
Choice D rationale
Watching for fetal compromise is necessary following PPROM as premature rupture of membranes can lead to umbilical cord compression or other complications affecting fetal oxygenation. Continuous fetal monitoring helps detect early signs of distress, allowing timely intervention to ensure fetal safety.
Correct Answer is D
Explanation
Choice A rationale
Placental abruption is characterized by abdominal pain, vaginal bleeding, and uterine tenderness. It does not cause dyspnea, hypotension, frothy sputum, or loss of consciousness.
Choice B rationale
Uterine rupture typically presents with severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Shock can occur, but not frothy sputum or sudden dyspnea.
Choice C rationale
Uterine inversion leads to pain, hemorrhage, and shock. It does not present with frothy sputum or sudden dyspnea.
Choice D rationale
Anaphylactoid syndrome (amniotic fluid embolism) results from amniotic fluid entering maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, matching the described scenario. .
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