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 D
Explanation
Choice A rationale
Positive Moro and stepping reflexes are normal findings in newborns and are not specifically associated with dehydration or SGA.
Choice B rationale
Scant vernix is common in full-term babies and not indicative of SGA or dehydration.
Choice C rationale
Blood glucose levels provided are within normal range for newborns and do not indicate dehydration.
Choice D rationale
Tenting of the skin and dry lips are signs of dehydration, which can be associated with SGA newborns due to insufficient fluid intake. .
Correct Answer is C
Explanation
Choice A rationale
Hypertonia, tachycardia, and metabolic alkalosis are not associated with necrotizing enterocolitis (NEC). NEC is characterized by gastrointestinal symptoms and signs of systemic illness.
Choice B rationale
Hypertension, apnea, and ruddy skin color are not specific indicators of necrotizing enterocolitis (NEC). NEC primarily presents with gastrointestinal symptoms and systemic instability.
Choice C rationale
Abdominal distention, temperature instability, and bloody stools are classic signs of necrotizing enterocolitis (NEC). These symptoms indicate severe inflammation and potential bowel necrosis.
Choice D rationale
Scaphoid abdomen, no residual with feedings, and increased urinary output are not characteristic of necrotizing enterocolitis (NEC). NEC typically presents with abdominal distention and feeding intolerance. .
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