The nurse is administering methylergonovine 0.2 mg to a healthy postpartum client with uterine atony.
Which assessment will the nurse need to make prior to administering the medication?
If blood pressure is lower than 140/90 mm Hg.
If hematocrit level is higher than 45%.
If urine output is higher than 50 ml/hr.
The Correct Answer is A
Choice A rationale
Methylergonovine is a vasoconstrictor that stimulates smooth muscle contraction in the uterus to control postpartum hemorrhage. However, this vasoconstrictive effect is not limited to the uterus and can cause a systemic increase in blood pressure. The medication is contraindicated in patients with hypertension, with a systolic blood pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg, to prevent a hypertensive crisis or cerebrovascular accident.
Choice B rationale
Hematocrit is the percentage of red blood cells in the blood and is used to assess for anemia or polycythemia. A normal hematocrit range for women is 37-47%. While anemia is a common concern postpartum, and a low hematocrit may indicate significant blood loss, it is not a primary contraindication for methylergonovine administration. The drug's primary side effect is related to blood pressure, not hematological status.
Choice C rationale
Urine output is an indicator of renal perfusion and overall hydration status. A normal urine output is typically greater than 30 ml/hr. While decreased urine output could indicate hypovolemia or renal dysfunction, it is not a direct contraindication for methylergonovine. The medication's effect on blood pressure is the primary safety consideration, not its effect on renal function or urine output.
Choice D rationale
Dizziness or lightheadedness can be a sign of orthostatic hypotension or blood loss. Assessing for dizziness is an important part of a postpartum assessment, but it is not a specific contraindication for methylergonovine. The medication's primary risk is hypertension, which is not directly related to a client's baseline experience of dizziness. A baseline blood pressure measurement is a more specific and crucial assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Painting a picture requires fine motor skills and a level of artistic expression that may be beyond a typical toddler's developmental stage. While some toddlers may enjoy making marks on paper, the structured activity of painting a picture is more appropriate for preschoolers. Toddlers are still developing hand-eye coordination and may become frustrated with a task that requires precision.
Choice B rationale
Playing peek-a-boo is a game typically enjoyed by infants who are learning about object permanence. While a toddler may still find it amusing, it is not the most developmentally appropriate activity for a hospitalized toddler who is developing gross motor skills, independence, and exploring their environment. The game does not support the toddler's need for autonomy and movement.
Choice C rationale
Listening to music can be a soothing and pleasant activity for a toddler, especially in a hospital setting. However, it is a passive activity. The most appropriate play for a toddler is one that engages their newfound gross motor skills, sense of autonomy, and exploration. A passive activity like listening to music does not fully meet the developmental needs of this age group.
Choice D rationale
Playing with a push-pull toy is the most appropriate activity for a toddler. Toddlers are in the developmental stage of mastering walking and running. These toys support the development of gross motor skills, coordination, and balance. The activity also encourages independent exploration and a sense of mastery, which aligns with the toddler's psychosocial stage of autonomy versus shame and doubt.
Correct Answer is D
Explanation
Choice A rationale
Chronic anemia is not a primary complication of Kawasaki syndrome. The disease process is a vasculitis that primarily affects medium-sized arteries, leading to inflammation and damage. The acute inflammatory state can cause temporary anemia, but it is not a chronic sequela prevented by IVIG and aspirin.
Choice B rationale
Cardiac arrhythmias are not the primary long-term complication targeted by IVIG and aspirin therapy. The main concern is the weakening of the coronary artery walls due to inflammation, which can lead to the formation of aneurysms. Arrhythmias can occur but are not the main focus of this specific treatment.
Choice C rationale
Acute respiratory distress is not a typical complication of Kawasaki syndrome. The syndrome is a systemic vasculitis, not a primary pulmonary disease. Respiratory symptoms like cough or runny nose are part of the initial presentation but are not the serious, life-threatening complication that IVIG and aspirin are given to prevent.
Choice D rationale
Coronary artery aneurysms are the most serious long-term complication of Kawasaki syndrome. The intense inflammation of the blood vessel walls, known as vasculitis, can lead to weakening and bulging of the coronary arteries. High-dose aspirin and IVIG reduce this systemic inflammation, thereby preventing the formation of these aneurysms.
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