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?
Elevate the head of the client's bed.
Administer a dose of terbutaline.
Initiate oxygen at 2 L/min via nasal cannula.
Initiate an infusion of oxytocin.
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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Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 12/min indicates that the respiratory depression caused by magnesium sulfate toxicity has been effectively reversed by calcium gluconate. Normal respiratory rate in adults is 12-20 breaths per minute.
Choice B rationale
Absent deep tendon reflexes indicate ongoing magnesium sulfate toxicity. Calcium gluconate administration should restore normal reflexes, not cause their absence.
Choice C rationale
Slurred speech is a sign of magnesium sulfate toxicity. Effective treatment with calcium gluconate should improve neurological function and resolve symptoms like slurred speech.
Choice D rationale
A urine output of 22 mL/hr is below the normal range and suggests renal impairment or ongoing toxicity. Effective treatment should result in an increase in urine output to within the normal range (greater than 30 mL/hr).
Correct Answer is A
Explanation
Choice A rationale
Fetal heart rate (FHR) accelerations with fetal movement are a sign of a healthy and reactive nonstress test. This indicates that the fetus is well-oxygenated and there is no immediate distress.
Choice B rationale
Late decelerations of the FHR occur with contractions and are a concern for fetal hypoxia. This does not indicate a reactive nonstress test and instead suggests the need for further evaluation.
Choice C rationale
Variable decelerations are abrupt decreases in FHR and could indicate umbilical cord compression. This does not correlate with a reactive nonstress test.
Choice D rationale
FHR pattern with minimal variability can be a sign of fetal distress or compromised oxygenation. It is not indicative of a reactive nonstress test.