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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 B

Explanation

Choice A rationale

A positive pregnancy test is a probable sign of pregnancy as it indicates the presence of hCG, a hormone produced during pregnancy. However, it is not a presumptive sign, as other

conditions can also result in elevated hCG levels.

Choice B rationale

Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy. It is one of the earliest indications that a woman may be pregnant, though it can also be

caused by other factors such as stress or hormonal imbalances.

Choice C rationale

Fetal heart sounds detected by Doppler ultrasound are a positive sign of pregnancy, confirming the presence of a fetus. This is not a presumptive sign as it is direct evidence of

pregnancy.

Choice D rationale

Chadwick's sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is considered a probable sign of pregnancy. It is not a presumptive sign but rather

a physical change that occurs during pregnancy. .

Correct Answer is B

Explanation

Choice A rationale

Cesarean birth is not necessarily required for GBS-positive clients as long as IV antibiotic prophylaxis is administered during labor to prevent transmission to the newborn.

Choice B rationale

IV antibiotic prophylaxis, typically with penicillin or ampicillin, is given to GBS-positive clients during labor to prevent neonatal GBS infection.

Choice C rationale

Obtaining a vaginal culture at 39 weeks of gestation is not necessary if the client was already screened and found positive for GBS at 36 weeks.

Choice D rationale

Metronidazole is used to treat bacterial vaginosis or trichomoniasis, not GBS infection; thus, it is not appropriate for this scenario. .

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