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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.

A. Remove your newborn’s electronic monitoring band for bathing. B. Limit visitors to your immediate family. C. Check identification badges of staff who enter your room. D. Send the newborn to the nursery while you are sleeping.

Correct Answer is C

Explanation

The nurse should provide the instruction to “verify the identity of anyone who wants to remove your baby from the room” in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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?