A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Massage the client's fundus.
Empty the client's bladder.
Provide oxygen to the client via nonrebreather face mask.
Administer oxytocin to the client.
The Correct Answer is A
A.
Rationale:
A. Massaging the client's fundus is the priority action to address excessive vaginal bleeding.
Massaging the fundus helps promote uterine contractions, which can help control bleeding by compressing blood vessels.
B. Emptying the client's bladder may be necessary to relieve pressure on the uterus, but it is not the first priority when addressing excessive bleeding.
C. Providing oxygen may be indicated if the client shows signs of hypoxia, but it is not the first action to address excessive vaginal bleeding.
D. Administering oxytocin may be necessary to help control bleeding, but massaging the fundus is the first step in managing postpartum hemorrhage.
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Related Questions
Correct Answer is C
Explanation
A. While an autopsy can be an option for determining the cause of stillbirth, it is not a requirement, and the decision should be made by the parents. This statement may add undue pressure on the client.
B. There is no legal requirement for parents to name a stillborn fetus. This can be a sensitive topic, and it is essential to respect the parents' wishes and feelings in this regard.
C. Providing the client with photos of the fetus can help the parents in their grieving process, allowing them to create memories and acknowledge their loss. This action can offer emotional support and validation of their experience.
D. Limiting the time the fetus is in the client's room may not consider the parents' need for closure and the opportunity to say goodbye. Encouraging the family to spend time with their stillborn child can be an important aspect of the grieving process.
Correct Answer is C
Explanation
Rationale:
A. A WBC count of 11,000/mm3 is slightly elevated but may be within normal limits, as the normal range for WBC count can vary slightly depending on the laboratory. It is not typically concerning during pregnancy.
B. A hematocrit of 37% is within the normal range for pregnancy (37% to 47%) and does not require immediate reporting to the provider.
C. A fasting blood glucose level of 180 mg/dL is significantly elevated and indicates hyperglycemia, which may be indicative of gestational diabetes mellitus or pre-existing diabetes. This finding should be reported to the provider for further evaluation and management.
D. A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL) and does not require immediate reporting to the provider.
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