A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?

Correct Answer: A

Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.

Correct Answer: B

Rationale: The correct answer is B: monitor fetal heart rate continuously. This is crucial because oxytocin can cause uterine hyperstimulation leading to fetal distress. Continuous monitoring allows for early detection of fetal compromise. Monitoring for signs of uterine hyperstimulation (A) is important but secondary to fetal well-being. Emotional support (C) and encouraging ambulation (D) are beneficial but not as critical as ensuring fetal safety during oxytocin administration.

Correct Answer: C

Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.

Correct Answer: B

Rationale: The correct initial action is to monitor blood pressure (B) because postpartum headache could indicate preeclampsia, a serious condition characterized by high blood pressure. Monitoring blood pressure is crucial to assess for signs of preeclampsia. Administering pain medication (A) may mask symptoms, performing a neurological assessment (C) may not address the underlying cause, and providing oxygen (D) is not the priority without knowing the cause of the headache.

Correct Answer: A

Rationale: The correct answer is A: Swelling and redness of the calf. Postpartum women are at a higher risk for DVT due to hormonal changes and immobility. Swelling and redness in the calf indicate possible DVT as blood clots can cause inflammation and blockage in the veins. Pain in the lower leg (B) is a common symptom but not the most specific for DVT. Heat intolerance (C) and cold intolerance (D) are not typically associated with DVT and are unrelated symptoms in this context.