A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

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Maternal Newborn ATI Quizlet Questions

Question 1 of 4

A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

Correct Answer: A

Rationale: The correct action for the nurse to take first is to evaluate the firmness of the uterus. This is because the client's low blood pressure may indicate postpartum hemorrhage, which is a common complication after childbirth. Assessing the firmness of the uterus helps determine if there is uterine atony, a leading cause of postpartum hemorrhage. By addressing uterine atony promptly, the nurse can prevent further blood loss and stabilize the client's condition. Summary: - Option B, initiating oxygen therapy, is not the first priority as the client's low blood pressure is likely due to hemorrhage rather than hypoxemia. - Option C, administering oxytocin infusion, may be necessary to address uterine atony but should only be done after assessing the firmness of the uterus. - Option D, obtaining a type and crossmatch, is important for potential blood transfusion but is not the immediate priority compared to assessing for uterine atony.

Question 2 of 4

A client in the antepartum unit is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

Correct Answer: D

Rationale: The correct answer is D, abruptio placentae. This condition is characterized by sudden onset of continuous abdominal pain and vaginal bleeding, common at 36 weeks gestation with pregnancy-induced hypertension. It occurs when the placenta prematurely separates from the uterine wall. Placenta previa (A) presents painless bleeding, prolapsed cord (B) involves cord presenting before the fetus, and incompetent cervix (C) leads to painless dilation of the cervix. Thus, abruptio placentae is the most likely complication in this scenario.

Question 3 of 4

During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?

Correct Answer: C

Rationale: During a Leopold maneuver, if the healthcare professional determines that the fetus is in an RSA position, it means the fetal back is on the right side, and the small parts are on the left side, indicating a breech presentation. Therefore, the correct answer is C: Breech. The other choices are incorrect because: A: Vertex refers to the head-first position. B: Shoulder presentation would involve feeling the shoulder first during the maneuver. D: Mentum presentation would involve feeling the chin first, which is not the case in an RSA position.

Question 4 of 4

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

Correct Answer: D

Rationale: The correct answer is D: Fetal position is persistent occiput posterior. This position, where the baby's head is facing the mother's abdomen instead of her back, can lead to severe backache and difficulty during labor due to increased pressure on the mother's spine. This malposition can impede the progress of labor and cause prolonged labor. Explanation of incorrect choices: A: Fetal attitude in general flexion is a normal position and not typically associated with severe backache. B: Fetal lie being longitudinal refers to the baby's position in relation to the mother's spine and is not directly related to backache. C: Maternal pelvis being gynecoid is a favorable shape for childbirth and is unlikely to cause severe backache during labor.

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