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A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?

A.

Elevate the head of the client's bed.

B.

Administer a dose of terbutaline.

C.

Initiate oxygen at 2 L/min via nasal cannula.

D.

Initiate an infusion of oxytocin.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.

 

Choice B rationale

Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.

 

Choice C rationale

Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.

 

Choice D rationale

Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat is typically detectable by Doppler around 10-12 weeks, not as early as 6 weeks.

Choice B rationale

Monthly prenatal visits up to 28 weeks are standard practice for monitoring pregnancy.

Choice C rationale

A complete blood count is not performed at every prenatal visit but at specific intervals.

Choice D rationale

The blood test for neural tube defects, such as AFP, is usually done around 16-18 weeks, not 32 weeks.

Correct Answer is D

Explanation

Choice A rationale

Instituting droplet precautions is not necessary for herpes simplex virus (HSV). HSV is primarily transmitted through direct contact with infected body fluids or lesions, not through respiratory droplets.

Choice B rationale

Administering ceftriaxone sodium is not appropriate for HSV. Ceftriaxone is an antibiotic used to treat bacterial infections, whereas HSV is a viral infection and requires antiviral treatment.

Choice C rationale

Informing the client they should bottlefeed the newborn is not necessary. Mothers with HSV can breastfeed as long as there are no herpetic lesions on the breast. Proper hand hygiene and preventive measures should be taken to avoid transmission.

Choice D rationale

Obtaining surface cultures from the newborn is the appropriate action. This helps in detecting the presence of HSV and initiating antiviral treatment if necessary. Early detection and treatment are crucial in preventing severe complications associated with neonatal HSV infection.

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