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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View Related questions
Correct Answer is ["B","C","D","E","F"]
Explanation
A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.
C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.
D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.
E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.
F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.
G. "This medication can increase your blood pressure.":
Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.
Correct Answer is D
Explanation
Choice A rationale
Starting each feeding with the most sore breast can worsen the condition, as the infant initially sucks more vigorously at the beginning of a feeding. This might increase the pain and damage to the already sore breast.
Choice B rationale
Moisture-proof lining in breast pads can cause an accumulation of moisture, creating a breeding ground for bacteria. This can exacerbate soreness and lead to infections such as mastitis.
Choice C rationale
Breastfeeding less frequently can lead to engorgement and plugged ducts, which can further complicate breast soreness and potentially decrease milk supply. Regular feeding helps in maintaining milk flow and production.
Choice D rationale
Colostrum has natural healing properties, including immunoglobulins and growth factors, that can help heal sore and cracked nipples. Applying colostrum can promote faster recovery and reduce discomfort.