Which action is most important for the nurse to implement?
Increase IV infusion rate.
Assess the vital signs.
Massage the fundus.
Notify the healthcare provider.
The Correct Answer is C
Choice A rationale
Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.
Choice B rationale
Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.
Choice C rationale
Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.
Choice D rationale
Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Visualization of implantation by vaginal ultrasound offers the highest accuracy in confirming pregnancy, as it directly visualizes the implanted embryo, eliminating errors associated with biochemical tests.
Choice B rationale
Maternal blood serum tests positive for alpha-fetoprotein do not confirm pregnancy. Alpha-fetoprotein is a marker used primarily for screening fetal abnormalities, not pregnancy determination.
Choice C rationale
The presence of amenorrhea for 2 months can suggest pregnancy but is not definitive due to other potential causes of missed periods, such as hormonal imbalances or stress, reducing its accuracy.
Choice D rationale
Reporting feeling tired all the time is a nonspecific symptom that can result from numerous conditions unrelated to pregnancy, making it an unreliable method for pregnancy determination.
Correct Answer is D
Explanation
Choice A rationale
Epidural placement requires assessing the current cervical dilation and fetal station. Without this information, premature epidural placement can impede labor progress or mask signs of complications.
Choice B rationale
A bolus of intravenous fluids is necessary before epidural anesthesia to prevent hypotension. However, assessing cervical dilation first ensures that it is appropriate to proceed with pain management.
Choice C rationale
Decreasing the oxytocin infusion rate is not the initial priority. The current cervical dilation and effacement need to be assessed to determine the appropriate management of labor and pain control.
Choice D rationale
Determining current cervical dilation is the first action to evaluate labor progress and make informed decisions regarding pain management and epidural placement, ensuring safe and effective care.
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