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 D

Explanation

Choice A rationale
Gestational diabetes mellitus is not a contraindication for a contraction stress test. This condition affects how the mother’s body uses glucose (sugar) during pregnancy, but it does not interfere with the ability to perform a contraction stress test.
Choice B rationale
A previous stillbirth is not a contraindication for a contraction stress test. A stillbirth refers to the loss of a baby after 20 weeks of pregnancy. While this is a significant event, it does not prevent the mother from undergoing a contraction stress test in a subsequent pregnancy.
Choice C rationale
A nonreactive nonstress test is not a contraindication for a contraction stress test. A nonreactive nonstress test indicates that the baby’s heart rate does not speed up (or “react”) as it should when the baby moves. However, this result does not prevent the mother from undergoing a contraction stress test.
Choice D rationale
A previous classical incision is a contraindication for a contraction stress test. A classical incision refers to a vertical cut in the upper part of the uterus, which is typically used during a cesarean section. This type of incision increases the risk of uterine rupture, which can be life- threatening for both the mother and the baby. Therefore, a contraction stress test, which induces contractions, should not be performed due to the risk of uterine rupture.

A. Provide the newborn with 15 mL glucose water after each feeding. B. Close the newborn’s eyes before applying eyepatches. C. Apply hydrating lotion to the newborn’s skin prior to treatment. D. Turn the newborn every hour.

Correct Answer is B

Explanation

Choice A rationale
Providing the newborn with 15 mL glucose water after each feeding is not a recommended action for a newborn undergoing phototherapy for jaundice. While maintaining adequate hydration is important, feedings should consist of breast milk or formula, unless otherwise directed by a healthcare provider.
Choice B rationale
Before starting phototherapy, it’s important to protect the newborn’s eyes from the light by applying eye patches. This can help prevent potential damage to the retinas.
Choice C rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not a recommended action for a newborn undergoing phototherapy for jaundice. The light needs to be able to penetrate the skin in order to break down the bilirubin, and applying lotion could potentially interfere with this process.
Choice D rationale
Turning the newborn every hour is not a recommended action for a newborn undergoing phototherapy for jaundice. While it’s important to change the newborn’s position regularly to ensure that all areas of the skin are exposed to the light, this does not need to be done on an hourly basis.

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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

In a prenatal clinic, a nurse is caring for a group of clients. Which client should the nurse identify as having a contraindication for a contraction stress test?

Correct Answer is D

Explanation

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Correct Answer is B

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?