A nurse admits a normal vaginal delivery to the maternity unit 2 hours ago.
The patient's fundus is firm at the umbilicus.
On admission, her vital signs are BP 108/64, Apical 90, RR 20, and Temp.
98.6°F. Suddenly, her lochia appears to be heavy, saturating the entire chux pad within 5 minutes.
At this time, the nurse's first priority action is:
Place the patient in a Trendelenburg position.
Notify the physician on call about the emergency.
Administer Methylergonovine 0.2 mg IM now.
Massage fundus until firm.
The Correct Answer is D
Choice A rationale
Placing the patient in a Trendelenburg position is not the immediate priority. This position is often used to manage shock or to improve blood flow to the brain, but it does not directly address the cause of heavy lochia. It may not be the most effective first intervention in this situation.
Choice B rationale
Notifying the physician is important, but the nurse should first attempt to control the bleeding. The physician can be notified after initial measures to stop the bleeding are taken. Immediate intervention by the nurse is crucial in this scenario to stabilize the patient.
Choice C rationale
Administering Methylergonovine can help control postpartum hemorrhage, but this should be done after attempting non-pharmacological measures like fundal massage. Methylergonovine can have side effects and should be used with caution.
Choice D rationale
Massaging the fundus until it is firm is the immediate priority. This can help expel clots and stimulate uterine contraction, which can reduce bleeding. It is a direct and immediate intervention to address the heavy lochia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Breast milk typically "comes in" within 3 to 5 days postpartum due to hormonal changes, particularly the increase in prolactin and decrease in progesterone.
Choice B rationale
Breast milk usually does not come in within 2 days postpartum because the hormonal changes required take a bit more time to occur.
Choice C rationale
Breast milk coming in around 10 days postpartum is later than usual and may indicate a delay or complication in lactation.
Choice D rationale
Breast milk coming in 6 to 8 days postpartum is somewhat later than the typical 3 to 5 day range, potentially indicating a minor delay in lactation.
Correct Answer is F
Explanation
Choice A rationale
Abnormal stool patterns can be a sign of various issues in newborns, but they do not align with the vital signs presented. The vital signs suggest a more systemic issue rather than one isolated to digestive patterns.
Choice B rationale
While temperature regulation is critical in newborns, especially those who are preterm, the vital signs presented suggest a broader systemic issue. The symptoms do not align with isolated temperature dysregulation.
Choice C rationale
Feeding difficulties can be a sign of neonatal abstinence syndrome but are not directly reflected in the vital signs presented. Neonatal Abstinence Syndrome (NAS) encompasses a range of withdrawal symptoms due to exposure to drugs in utero, not just feeding issues.
Choice D rationale
While extremity issues can be present in various neonatal conditions, they do not align with the systemic symptoms shown in the vital signs. NAS impacts multiple body systems and would present more generalized symptoms.
Choice E rationale
Hypoglycemia can present with some of these vital signs, such as a rapid heart rate, but it does not explain all the symptoms like increased respiratory rate and temperature dysregulation. It is a condition that requires monitoring but is not the primary diagnosis suggested here.
Choice F rationale
Neonatal Abstinence Syndrome is consistent with the vital signs: elevated heart rate, increased respiratory rate, and lower temperature. NAS results from withdrawal from substances the newborn was exposed to in utero and affects multiple body systems, explaining the range of symptoms.
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