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 D
Explanation
Choice A rationale
A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.
Choice B rationale
Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.
Choice C rationale
Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.
Choice D rationale
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.
Correct Answer is D
Explanation
Choice A rationale
Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.
Choice B rationale
Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.
Choice C rationale
An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.
Choice D rationale
Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.