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 ["B","C","D"]
Explanation
Choice A rationale
Hypertension is not a characteristic finding of hyperemesis gravidarum, which primarily affects fluid balance and nutritional status.
Choice B rationale
Dry mucous membranes are a sign of dehydration, commonly associated with hyperemesis gravidarum due to excessive vomiting.
Choice C rationale
Tachycardia can result from dehydration and electrolyte imbalances seen in hyperemesis gravidarum.
Choice D rationale
Poor skin turgor indicates dehydration, a common symptom of hyperemesis gravidarum.
Choice E rationale
Polyuria is not typical in hyperemesis gravidarum; the condition usually leads to dehydration, reducing urine output.
Correct Answer is A
Explanation
Choice A rationale
Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early
detection and management of any potential infections.
Choice B rationale
Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage,
not for routine use post-amniotomy.
Choice C rationale
Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.
Choice D rationale
Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .