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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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Correct Answer is B

Explanation

Choice A rationale

Informing the client to expect dark-colored stools is inaccurate for methotrexate administration. Dark stools typically indicate gastrointestinal bleeding, not a side effect of methotrexate.

Choice B rationale

Wearing two pairs of gloves is necessary when handling methotrexate as it is a cytotoxic drug. This protects healthcare workers from accidental exposure to the medication, which can be harmful.

Choice C rationale

Methotrexate is typically administered intramuscularly or orally, not subcutaneously. Administering it subcutaneously is incorrect and would not be effective for treating an ectopic pregnancy.

Choice D rationale

While it is essential to counsel the client on safe intercourse practices, instructing to use a condom for only 7 days post-administration is not specific or relevant to the methotrexate therapy for ectopic pregnancy.

Correct Answer is B

Explanation

Choice A rationale

Meconium stools are common in newborns and not a concern in the context of weight loss.

Choice B rationale

Depressed fontanels can indicate dehydration in a newborn, which is critical, especially with significant weight loss.

Choice C rationale

Rust-stained urine is often due to urate crystals and is typical in newborns, not specifically alarming.

Choice D rationale

Overlapping suture lines can be a normal finding in a newborn's head and not indicative of an acute problem relating to weight loss.

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