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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby." Chorionic villus sampling (CVS) is a different prenatal test that involves taking a sample of chorionic villi for genetic testing, not determining the sex of the fetus.
B. "This procedure determines if your baby has genetic or congenital disorders."
Correct answer.
Amniocentesis is a prenatal test used to diagnose genetic disorders or chromosomal abnormalities, not to determine the sex of the fetus.
C. "We can schedule the procedure for later today if you'd like." Amniocentesis is not typically scheduled on the same day as requested. It requires prior preparation and scheduling.
D. "You cannot have an amniocentesis until you are at least 35 years of age." There's no age restriction for amniocentesis based solely on maternal age. It's typically recommended for women at higher risk for genetic conditions, regardless of age.
Correct Answer is C
Explanation
Rationale:
A. Applying an ice pack to the incision site is not indicated for addressing vaginal bleeding after cesarean birth and may not effectively address the underlying cause.
B. Replacing the surgical dressing is not the first action to take when assessing vaginal bleeding after cesarean birth. The priority is to evaluate the client's condition and identify the cause of the bleeding.
C. Evaluating urinary output is important to assess for urinary retention, which can contribute to uterine atony and postpartum bleeding. A full bladder can interfere with uterine contraction and lead to increased bleeding.
D. Administering a lactated Ringer's IV bolus may be indicated if the client is hypovolemic due to excessive bleeding, but it is not the first action to take. Assessing urinary output and addressing potential causes of bleeding take precedence.
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