Jacob McGinnis Maternal DQ_2 25

A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement? (Click on "Exhibit NCLEX 1" under Resources on the righthand side for additional information about the client) X @ A. Encourage the client to use a hot pack on the perineum v {__ B. Administer ferrous sulfate orally __ C.Help the client apply a breast binder __) D. Administer Rh immune globulin Graded Response: Incorrect Correct Answer: B. Administer ferrous sulfate orally Peer Comparison or |} = I Incorrect Answers: c| A. The nurse should encourage the client to use a cold pack on the perineum to decrease edema and promote comfort. D . The nurse should administer ferrous sulfate orally for a client who has a hemoglobin level of 10.5 g/dL. C. The nurse can assist with applying a breast binder or a well-fitted support bra to relieve discomfort for a client who does not plan to breastfeed. D. The nurse should administer Rh immune globulin within 72 hours of birth to clients who are Rh-negative and have a newborn who is Rhpositive. A nurse is caring for a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart rate tracing. Which of the following actions should the nurse take? X @) A. Discontinue oxytocin infusion and apply oxygen __/ B. Increase oxytocin infusion rate by 2 mu/min __J C. Administer terbutaline 0.25 mg subcutaneously v __ D.Reposition the client in a side-lying position and continue to monitor Graded Response: Incorrect Correct Answer: D. Reposition the client in a side-lying position and continue to monitor Peer Comparison A Category 1 fetal heart rate tracing is an expected finding and does not represent fetal distress. The nurse should reposition the clientin a side-lying position to optimize uteroplacental perfusion and continue to monitor the tracing for another 10 minutes to determine if tachysystole resolves. C I Incorrect Answers: A. The nurse should discontinue the oxytocin infusion and apply oxygen for a Category 2 (indeterminate) or Category 3 (abnormal) fetal heart rate tracing. B. The nurse should not increase the oxytocin infusion when the client is experiencing tachysystole because tachysystole can cause fetal distress. C. The nurse should administer terbutaline 0.25 mg subcutaneously for a Category 2 or Category 3 fetal heart rate tracing if discontinuing the oxytocin does not resolve the tachysystole.