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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.

Answer and Explanation

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. .

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale

Checking for ketones in urine is related to metabolic conditions like diabetic ketoacidosis, not directly relevant to the immediate care of an eclamptic client.

Choice B rationale

Padding the bed rails and headboard helps prevent injury during seizures, which is crucial in managing a client with eclampsia.

Choice C rationale

Providing visual and auditory stimulation can increase the risk of further seizures in an eclamptic client. Reducing stimulation is usually recommended.

Choice D rationale

Placing the bed in the high Fowler's position is not appropriate for managing a client post-seizure. The priority is ensuring airway patency and preventing injury.

A. Check the blood sugar of a gestational diabetic. B. Assess the vaginal blood loss of a client who is recovering from a spontaneous abortion. C. Assess the patellar reflexes of a client with pre-eclampsia without severe features. D. Check the fetal heart rate of a client whose membranes just ruptured.

Correct Answer is D

Explanation

Choice A rationale

Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.

Choice B rationale

Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.

Choice C rationale

Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.

Choice D rationale

Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a new staff member caring for an eclamptic client following a seizure.Which of the following actions by the staff member indicates an understanding of eclampsia?

Correct Answer is B

Explanation

A nurse is triaging four clients on the labor and delivery unit.Which of the following actions should be a priority for nursing care?

Correct Answer is D

Explanation

A client with an obstetrical history of G1 P0000 received dinoprostone for cervical ripening 8 hours ago.The Bishop score at that time was 4. The Bishop score is now 10. Which of the following actions by the nurse is appropriate?

When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to:

A preterm labor client at 30 weeks' gestation reported rupture of membranes 4 hours ago.This was confirmed on examination.The nurse prepares to administer IM dexamethasone.When the client asks why she is receiving the drug, the nurse replies:

A gravid patient in labor suddenly has dyspnea, hypotension, frothy sputum, and loss of consciousness.The nurse knows these are signs and symptoms of which obstetrical emergency?

There are four clients in active labor in the labor suite.Which of the clients should the nurse monitor carefully for a potential uterine rupture?

The nurse is assisting the primary care provider (PCP) with the third stage of a vaginal delivery.The patient is multiparous, experienced a precipitous birth, and has a history of hypertension.Which medical prescription does the nurse anticipate for this patient?

During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred.Which of the following actions by the nurse is appropriate at this time?

The nurse educator is preparing a presentation on preterm labor (PTL) and birth (PTB). Which information does the nurse recognize as being inaccurate?