Nokea
A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?
- A. Administer 10 units oxytocin IM
- B. Apply oxygen via nonrebreather facemask at 10 L/min
- C. Assist the client to void on a bedpan
- D. Obtain blood for a hemoglobin and hematocrit level
Correct Answer: C
Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.
You may also like to solve these questions
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
- A. Document the output and vital signs
- B. Draw blood for hemoglobin and hematocrit
- C. Lower the head of the bed
- D. Notify the registered nurse
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.
The nurse is caring for an older adult client who has experienced recent multiple falls and weight loss. The client lives with an adult child, but the nurse is questioning the safety of the home. Which of the following interdisciplinary team members would be most appropriate for the nurse to consult?
- A. adult protective services
- B. physical therapist
- C. social worker
- D. physician
Correct Answer: C
Rationale: A social worker can assess the home environment, coordinate resources for safety modifications, and address caregiving concerns, making them the most appropriate consult for home safety evaluation.
A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.
- A. Ensure that informed consent has been obtained
- B. Place the client in reverse Trendelenburg position
- C. Place the client on NPO status
- D. Request the client empty their bladder
- E. Take baseline vital signs and weight
Correct Answer: A,D,E
Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.
The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to
- A. obtain a pulse oximetry reading for the client
- B. offer the client medication prescribed PRN for pain
- C. check the client's lower extremities for warmth and redness
- D. encourage guided imagery and breathing techniques for relaxation
Correct Answer: A
Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.
A client with acquired immunodeficiency syndrome is admitted with a diagnosis of pneumocystis jirovecki pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based on his mental status, the priority nursing diagnosis is:
- A. Social isolation
- B. Risk for self-injury
- C. Ineffective coping
- D. Anxiety
Correct Answer: B
Rationale: The client's confusion and attempts to remove medical devices indicate a risk for self-injury, making this the priority nursing diagnosis.