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
Anticonvulsants can induce liver enzymes, increasing the metabolism of combined oral contraceptives (COCs) and reducing their effectiveness.
Choice B rationale
Antihypertensives do not have a significant impact on the effectiveness of COCs.
Choice C rationale
Antioxidants do not interfere with the metabolism or effectiveness of COCs.
Choice D rationale
Antibiotics, except for rifampin, typically do not reduce the effectiveness of COCs.
Correct Answer is C
Explanation
Choice A rationale
The Moro reflex is a startle response in newborns and does not assist in promoting latching during breastfeeding.
Choice B rationale
The stepping reflex, also known as the walking reflex, involves a newborn making stepping movements when held upright and does not contribute to latching during breastfeeding.
Choice C rationale
The rooting reflex causes a newborn to turn their head toward a touch on their cheek and begin sucking movements, which is crucial for promoting latching during breastfeeding.
Choice D rationale
The Babinski reflex involves the toes fanning out when the sole of the foot is stroked and is unrelated to latching during breastfeeding. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.