Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
A. Evaluate the firmness of the uterus (fundus).
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
B. Obtain a type and crossmatch.
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
C. Administer oxytocin infusion.
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
D. Initiate oxygen therapy by nonrebreather mask.
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom 2023 Fall NPRO 1100 Proctored Exam 3. Take the full exam now
Full Explanation
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
Similar Questions
The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider.
Which signs and symptoms would the nurse include? Select all that apply.
A. Nausea with vomiting during the first trimester.
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
B. Sudden leakage of fluid during the second trimester.
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
C. Urinary frequency in the third trimester.
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
D. Backache during the second trimester.
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
E. Lower abdominal pain with shoulder pain in the first trimester.
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
F. Headache with visual changes in the third trimester.
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
Full Explanation
The correct answers are choices B, E, and F.
Choice A rationale:
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
Choice B rationale:
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
Choice C rationale:
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
Choice D rationale:
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
Choice E rationale:
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
Choice F rationale:
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
A nurse is teaching about crib safety with the parent of a newborn.
Which of the following statements by the client indicates understanding of the teaching?.
A. "I will place my baby on his stomach when he is sleeping.”. .
Placing a baby on their stomach while sleeping is not recommended due to the risk of Sudden Infant Death Syndrome (SIDS).
B. "I should remove extra blankets from my baby's crib.”. .
Removing extra blankets from the crib is a safety measure to prevent suffocation and overheating, which can lead to SIDS.
C. "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps.”. .
Padding the mattress in the crib can pose a suffocation risk for the baby.
D. "I will have my baby sleep in his own bedroom where the crib is.”.
It’s recommended for newborns to sleep in the same room as their parents for at least the first six months to reduce the risk of SIDS.
Full Explanation
The correct answer is choice B.
Choice A rationale:
Placing a baby on their stomach while sleeping is not recommended due to the risk of Sudden Infant Death Syndrome (SIDS).
Choice B rationale:
Removing extra blankets from the crib is a safety measure to prevent suffocation and overheating, which can lead to SIDS.
Choice C rationale:
Padding the mattress in the crib can pose a suffocation risk for the baby.
Choice D rationale:
It’s recommended for newborns to sleep in the same room as their parents for at least the first six months to reduce the risk of SIDS.
A woman gives birth to a small infant with a malformed skull.
The infant grows abnormally slowly and shows signs of substantial cognitive and intellectual deficits.
The child also has facial abnormalities including a short nose and thin lip that become more striking as it develops.
A. Active herpes simplex infection.
Active herpes simplex infection during pregnancy can lead to neonatal herpes, which is a serious condition, but it does not cause the symptoms described.
B. Chronic cocaine use.
Chronic cocaine use during pregnancy can lead to premature birth and low birth weight, but it does not typically result in the specific symptoms described.
C. Folic acid deficiency.
Folic acid deficiency during pregnancy can lead to neural tube defects, which can cause a range of symptoms, but not the specific ones described.
D. Chronic alcohol use.
Chronic alcohol use during pregnancy can lead to Fetal Alcohol Syndrome, which includes slow growth, cognitive and intellectual deficits, and the facial abnormalities described.
E. Folic acid deficiency.