The nurse has just administered intravenous (IV) methylergonovine (Methergine) to a postpartum patient to prevent bleeding. Later in the shift, the patient begins to vomit and complains of nausea and a headache
The nurse initially should assess the patient's a. bleeding status.
b. blood pressure.
c. headache.
d. renal function.
B
The nurse should assess the patient's blood pressure first. Hypertension can be severe and may be associated with nausea, vomiting, headache, and convulsions. Death also is possible.
Nothing indicates that the patient's bleeding status needs to be checked; the symptoms described are associated with hypervolemia.
Migraine may occur with methylergonovine, but the initial assessment should be the blood pres-sure.
Nothing indicates that the kidneys are being affected.
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