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 A
Explanation
A. "The car seat should be positioned in the car at a 45-degree angle." This statement is correct and indicates an understanding of car seat safety. Positioning the car seat at a 45-degree angle helps prevent the newborn's head from flopping forward, which could obstruct the airway. Proper positioning ensures both safety and comfort during travel.
B. "My baby will need a car seat challenge test before discharge." This statement is incorrect for a newborn delivered at 38 weeks of gestation. A car seat challenge test is typically required for premature infants (less than 37 weeks gestation) or those with specific health conditions to ensure they can tolerate sitting in a car seat without respiratory or cardiac issues.
C. "When my baby is 1 year old, I can turn their car seat facing forward." Incorrect. It is recommended to keep infants in a rear-facing car seat until they reach the maximum height or weight limit recommended by the car seat manufacturer, typically well beyond the first year of life.
D. “I can use a sleep sack to keep my baby warm in the car seat." While using a sleep sack can keep a baby warm, it's important not to use any additional padding or blankets in the car seat as they can interfere with the proper harness fit and increase the risk of injury in the event of a crash.
Correct Answer is B
Explanation
Rationale:
A. A blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not require immediate reporting to the provider.
B. Cool clammy skin may indicate hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This finding should be reported promptly for further evaluation and intervention.
C. Moderate lochia serosa is a normal finding in the early postpartum period and does not typically require immediate reporting.
D. A heart rate of 89/min is within the normal range for a postpartum client and does not require immediate reporting to the provider.
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