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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should use fingers to exert upward pressure on the presenting part to relieve cord compression, which is the immediate priority in this emergency situation.
Choice B rationale:
Administering a tocolytic medication is not the immediate priority. It may be done later to inhibit uterine contractions.
Choice C rationale:
Applying oxygen to the client is important, but it’s not the first action. The nurse needs to relieve cord compression first.
Choice D rationale:
Wrapping the cord in a sterile towel and moistening with warm sterile normal saline is important, but it’s not the first action. The nurse needs to relieve cord compression first.
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