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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A temperature of 37.4°C (99.3°F) may be within the normal range, but it can also indicate a fever, which is common with endometritis.
B. A WBC count of 9,000/mm3 is within the normal range, but it may be elevated in response to infection such as endometritis.
C. Scant lochia is not typically associated with endometritis; instead, clients with endometritis may have increased or foul-smelling lochia.
D. Uterine tenderness is a common finding in clients with endometritis, as the infection causes inflammation and discomfort in the uterine lining.
Correct Answer is A
Explanation
A. Administering broad-spectrum antibiotics is important because a leaking myelomeningocele increases the newborn’s risk for infection, including meningitis. Early prophylactic antibiotic therapy helps prevent serious complications.
B. Cleansing the site with povidone-iodine is not recommended because antiseptics can irritate neural tissue and worsen leakage. The sac should be kept sterile and moist using a saline-soaked sterile dressing instead.
C. Monitoring rectal temperature is contraindicated because rectal manipulation can risk trauma to the myelomeningocele sac. Noninvasive temperature monitoring, such as axillary measurement, is safer.
D. Surgical closure should be performed as soon as possible, ideally within 24–48 hours after birth, rather than waiting 72 hours, to reduce the risk of infection and further neurologic damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.