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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 A

Explanation

Choice A rationale

Irregular heartbeat (palpitations or arrhythmias) can indicate a serious cardiovascular side effect of nifedipine. It requires immediate medical attention as it could compromise

maternal and fetal circulation.

Choice B rationale

Hair loss is not a known adverse effect of nifedipine and generally does not pose a significant health risk. It is more commonly associated with hormonal changes rather than

medication side effects.

Choice C rationale

Increased salivation is not a common side effect of nifedipine. Nifedipine primarily affects the cardiovascular system rather than salivary glands.

Choice D rationale

Pause is not a recognized adverse effect related to nifedipine usage. The term itself is ambiguous and not typically associated with the pharmacological profile of nifedipine.

Correct Answer is D

Explanation

Choice A rationale

Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.

Choice B rationale

A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.

Choice C rationale

Late decelerations are concerning and not expected as they may indicate fetal distress.

Choice D rationale

Contractions lasting about 75 seconds are expected during the active phase of labor.

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