A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.

Which of the following actions should the nurse take first?

Collect hemoglobin and hematocrit levels.

Insert an indwelling urinary catheter.

Administer oxygen via face mask at 10 L/min.

Prepare the client to receive a plasma expander.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.

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Correct Answer is A

Explanation

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

Subtract 3 months from June 21, which gives you March 21.
Add 7 days to March 21, which gives you March 28.
Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

A. The client urinates 30 mL/hr. B. The client does not feel the urge to urinate. C. The uterine fundus is 2 cm above the umbilicus. D. The bladder is distended upon palpation.

Correct Answer is A

Explanation

Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.

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A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is calculating the estimated date of birth using Nägele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year?

Correct Answer is A

Explanation

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

Correct Answer is A

Explanation

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A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.

Which of the following actions should the nurse take first?