Hemabate has been ordered for a postpartum patient who has uncontrolled bleeding and uterine atony. Which is the appropriate nursing action?

Correct Answer: C

Rationale: In this scenario, option C is the appropriate nursing action. Hemabate is a medication used to address postpartum hemorrhage by causing uterine contractions. Checking the patient's record for a history of asthma is crucial because Hemabate can exacerbate asthma symptoms due to its potential bronchoconstrictive effects. By identifying this history, the nurse can prevent potential complications and ensure patient safety by avoiding unnecessary risks. Option A is incorrect because checking for hypotension and lowering the head of the bed are not directly related to the administration of Hemabate for uterine atony. Option B is incorrect as checking blood glucose and increasing IV fluids are not specific actions related to administering Hemabate for postpartum hemorrhage. Option D is incorrect because checking for a history of hypothyroidism and ordering anti-nausea medication are not directly relevant to the administration of Hemabate for controlling postpartum bleeding. Educationally, this scenario highlights the importance of thorough patient assessment and medication administration considerations based on individual patient histories to ensure safe and effective care delivery in postpartum situations. Nurses must be aware of potential medication side effects and contraindications to prevent adverse outcomes and promote patient well-being.

Correct Answer: C

Rationale: In this scenario, option C, which is to remove the IV, restart it in a new location, and complete the antibiotic administration, is the correct course of action for the nurse. The red, inflamed, and swollen IV site, along with tenderness and soreness reported by the patient, indicate phlebitis, an inflammation of the vein. Continuing the IV in the same location poses risks of infection and further complications. Option A is incorrect as flushing the IV with normal saline will not address the underlying issue of phlebitis. Option B is not the priority in this situation as the main concern is the compromised IV site. Option D is dangerous as allowing the IV to continue dripping slowly can lead to further complications. Educationally, this scenario highlights the importance of recognizing signs of IV complications such as phlebitis and the appropriate nursing interventions to ensure patient safety and optimal treatment delivery. Nurses must be vigilant in assessing IV sites and be prepared to take prompt action to prevent complications and provide effective care.

Correct Answer: A

Rationale: In postpartum hemorrhage leading to hematoma, rectal pain accompanied by a rising pulse (Option A) is a significant sign. This is because a hematoma is a localized collection of blood outside blood vessels, often causing pain in the affected area. The rising pulse indicates the body's response to increased blood loss, which is a critical sign of postpartum hemorrhage. Option B, cramping accompanied by a steady trickle of blood, is more indicative of normal postpartum contractions and bleeding. Option C, a soft uterine fundus and falling blood pressure, suggests uterine atony leading to hemorrhage but not specifically related to hematoma formation. Option D, heavy lochia accompanied by tachypnea and dyspnea, may indicate other complications like pulmonary embolism but does not directly point towards hematoma formation. Educationally, understanding the specific signs and symptoms of postpartum complications like hematoma is crucial for healthcare providers to provide timely and appropriate interventions to prevent further complications and ensure maternal well-being post-delivery. It is essential to differentiate between various postpartum complications to provide effective care and prevent adverse outcomes.

Correct Answer: D

Rationale: In the context of postpartum care, when a woman is receiving heparin therapy, it is crucial to have protamine sulfate readily available. Protamine sulfate is the antidote for heparin, a common anticoagulant used to prevent blood clots. If a woman on heparin therapy experiences excessive bleeding or needs urgent reversal of the anticoagulant effects, protamine sulfate can quickly neutralize the effects of heparin, thereby preventing serious complications like hemorrhage. Option A, Vitamin K, is not directly related to reversing the effects of heparin. Vitamin K is commonly used to treat coagulation disorders related to deficiencies in clotting factors, particularly in newborns. Option B, Methylergonovine, is a medication used to prevent or control postpartum hemorrhage by inducing uterine contractions. It is not indicated for reversing the effects of heparin therapy. Option C, Ferrous sulfate, is an iron supplement used to treat or prevent iron deficiency anemia. It is not relevant to the scenario of a woman on heparin therapy requiring an antidote. Understanding the appropriate antidotes and reversal agents for medications is essential in clinical practice, especially in situations where prompt intervention is necessary to ensure patient safety and optimal outcomes. Healthcare providers should be knowledgeable about the specific antidotes for commonly used medications to address potential complications effectively.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Reporting foul-smelling lochia and fever. This is crucial because the clinical presentation indicates a potential postpartum infection, most likely endometritis due to prolonged rupture of membranes and instrument-assisted delivery. Teaching this client to recognize signs of infection is vital for early intervention and prevention of complications. Option B) Delaying intercourse for at least 6 weeks is a standard recommendation postpartum but is not the priority in this case where infection signs are more critical to address promptly. Option C) Eating a diet high in iron and vitamin C is important for postpartum recovery but is not the priority when signs of infection are present, as addressing infection takes precedence. Option D) Losing weight over at least a 6-month period is not relevant to the immediate postpartum period and does not address the current clinical concern of potential infection. Educationally, this question highlights the importance of client education in recognizing and reporting postpartum complications, emphasizing the significance of early detection and intervention in improving outcomes for postpartum women. It underscores the need for healthcare providers to educate clients on signs and symptoms to watch for after childbirth, promoting their active participation in their own postpartum care.