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A nurse is caring for a client who is 8 hours postpartum
and is experiencing hemorrhage. Which of the following
actions should the nurse implement after notifying the
provider? (Select all that apply)
a. Massage the fundus
b. Give oxygen at 2L/min via nasal cannula
c. Administer oxytocin
d. Insert an indwelling catheter
,e. Place the client in a lateral position with her legs
elevated 30 degrees - ANSWER-Massage the fundus
Administer oxytocin
Insert an indwelling catheter
Place the client in a lateral position with her legs elevated
30 degrees
While assessing a client in the fourth stage of labor, the
nurse suspects bladder distention. Which of the following
findings would the nurse expect to see?
a. The fundus is displaced from the midline
b. The uterus is firm.
c. The fundus is below the umbilicus.
,d. The bladder is resonant with percussion - ANSWER-
The fundus is displaced from the midline
A nurse is testing the reflexes of a newborn to assess
neurological maturity. Which of the following reflexes is the
nurse assessing by holding the newborn upright with feet
touching a flat surface?
a. Babinski Reflex
b. Moro Reflex
c. Stepping Reflex
d. Plantar Grasp Reflex - ANSWER-Stepping Reflex
, The nurse in the newborn nursery has just received report.
Which of the following infants should the nurse see
FIRST?
a. A 2 day old infant who is lying quietly alert with a heart
rate of 185
b. A 1 day old infant who is crying and has a bulging
anterior fontanel
c. A 12 hour old infant who is being held, with respirations
that are 45 breaths per minute and regular
d. A 5 hour old infant who is sleeping and whose hands
and feet are blue bilaterally - ANSWER-A 2 day old infant
who is lying quietly alert with a heart rate of 185