A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.
What should the nurse do first?
Administer Oxytocin to the client
Massage the client’s fundus
Provide oxygen to the client via non-rebreather face mask
Empty the client’s bladder
The Correct Answer is B
Choice A rationale
Administering Oxytocin to the client is an important intervention for postpartum hemorrhage, but it is not the first action the nurse should take. Oxytocin stimulates uterine contractions which can help control bleeding, but it should be administered after the initial steps of assessing the uterus and ensuring it is firm.
Choice B rationale
Massaging the client’s fundus is the priority action to address excessive vaginal bleeding. A firm, well-contracted uterine fundus often helps to control postpartum bleeding. If the uterus is not well contracted, gentle massage is often sufficient to stimulate contractions. If the uterus does not respond to massage, then further interventions such as administering Oxytocin may be necessary.
Choice C rationale
Providing oxygen to the client via a non-rebreather face mask is an intervention that might be necessary if the client shows signs of hypoxia or shock as a result of the bleeding. However, it is not the first action that should be taken.
Choice D rationale
Emptying the client’s bladder is important as a distended bladder can displace the uterus and interfere with contractions, leading to increased bleeding. However, this is not the first action to take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Washing a baby’s face with plain water is a safe and effective way to keep it clean without causing irritation or dryness. This is especially important for newborns, whose skin is more sensitive than that of older children and adults.
Choice B rationale
Bumper pads are not recommended for use in a baby’s crib. They pose a risk of suffocation, strangulation, and entrapment. Instead, the crib should be kept bare, with only a firm mattress and a fitted sheet.
Choice C rationale
A soft mattress is not safe for a baby’s crib. It increases the risk of sudden infant death syndrome (SIDS) because it can conform to the shape of the baby’s head or face, leading to suffocation. A firm mattress is recommended.
Choice D rationale
Bathing a baby immediately after feeding is not recommended. It can cause discomfort and may lead to vomiting. It’s better to wait at least a little while after a feeding before bathing the baby.
Correct Answer is D
Explanation
Choice A rationale
Avoiding performing sterile vaginal examinations does not directly address the issue of uterine atony and excessive bleeding. While limiting vaginal examinations can reduce the risk of infection, it does not treat uterine atony.
Choice B rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication that is often given to pregnant women who are at risk of preterm birth to help mature the baby’s lungs. It does not treat uterine atony or excessive bleeding.
Choice C rationale
Obtaining a specimen for a Kleihauer-Betke test is not the appropriate action in this situation. The Kleihauer-Betke test is used to detect fetal blood in maternal circulation, which is not relevant in this case.
Choice D rationale
Anticipating a prescription for misoprostol is the correct action. Misoprostol is a medication that can be used to treat uterine atony by causing the uterus to contract, which can help control postpartum bleeding.
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