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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?

A.

Administer Oxytocin to the client

B.

Massage the client’s fundus

C.

Provide oxygen to the client via non-rebreather face mask

D.

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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Related Questions

Correct Answer is ["8"]

Explanation

Step 1 is to determine the total amount of metronidazole needed, which is 2 g.

Step 2 is to convert grams to milligrams, as the available medication is in milligrams. So, 2 g is equal to 2000 mg.

Step 3 is to calculate the number of tablets needed. Each tablet contains 250 mg of metronidazole. Therefore, the calculation is 2000 mg ÷ 250 mg/tablet.

Correct Answer is C

Explanation

Choice A rationale
Contractions feeling further apart is not a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice B rationale
Feeling relief from pelvic pressure may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice C rationale
Improvement in back labor is a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice D rationale
Lessening of suprapubic pain may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.

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