a nurse is caring for a client who gave birth 2 hr ago the nurse notes that the clients blood pressure is 6050 mm hg which of the following actions sh a nurse is caring for a client who gave birth 2 hr ago the nurse notes that the clients blood pressure is 6050 mm hg which of the following actions sh
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Maternal Newborn ATI Quizlet

1. 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: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.

2. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.

3. A 4-year-old boy ingested an unknown quantity of drain cleaner. He is alert, has a patent airway, and has adequate breathing. You should:

Correct answer: C

Rationale: When a child ingests a harmful substance like drain cleaner and remains alert with a patent airway and adequate breathing, the initial steps involve contacting poison control to guide further management. In this scenario, providing oxygen to support respiratory function is essential until definitive care is established. Activated charcoal and ipecac are not recommended in the management of ingested caustic substances like drain cleaner. Performing a head-to-toe exam can wait until the child's immediate respiratory needs are addressed and the poison control center has provided guidance on further management.

4. Mucus is produced by the salivary glands and the:

Correct answer: A

Rationale: Mucus is produced by the salivary glands to moisten food and aid in swallowing. Additionally, the intestinal glands secrete mucus to protect the lining of the intestines. The other choices, esophageal glands, pineal gland, and islets of Langerhans, are not involved in the production of mucus in the digestive system.

5. How should the nurse prepare the sibling of a near-drowning accident victim who wants to see his brother in the pediatric intensive care unit, considering the child was present during the accident?

Correct answer: D

Rationale: When preparing a sibling to see their brother in the pediatric intensive care unit after a near-drowning accident, it is essential to cover tubes and wires with a sheet, wash off any existing blood, and explain what the sibling will see. This approach helps the sibling understand the situation better and prepares them emotionally for the encounter, reducing potential distress and trauma. By providing information and visual preparation, the sibling can have a more controlled and less overwhelming experience when visiting their brother in the intensive care unit. Choice A is incorrect as informing the child that this could be the last time he sees his sibling may cause unnecessary distress and anxiety. Choice B is incorrect as it dismisses the sibling's emotional response, which is essential to address in a supportive manner. Choice C is incorrect as honesty and appropriate information sharing are crucial, even in difficult situations, to help the child cope effectively with the circumstances.

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