A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes. Which of the following actions is the highest priority?

Perform fundal massage

Weigh the perineal pad

Apply oxygen by face mask

Monitor urine output

Answer and Explanation

The Correct Answer is A

(A) Perform fundal massage:
Performing fundal massage is the highest priority action in this scenario. Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, which could indicate postpartum hemorrhage (PPH). Fundal massage helps to stimulate uterine contractions, which can aid in controlling bleeding by compressing blood vessels at the placental site. It is essential to assess the fundus for firmness and position and massage it if necessary, to prevent or manage PPH.

(B) Weigh the perineal pad:
Weighing the perineal pad can provide information about the amount of blood loss, but it is not the highest priority action at this moment. Fundal massage takes precedence to address the potential underlying cause of excessive bleeding.

(C) Apply oxygen by face mask:
While oxygen therapy may be indicated in certain situations, such as respiratory distress, it is not the highest priority in this scenario. The priority is to address the potential cause of excessive bleeding and prevent further complications associated with postpartum hemorrhage.

(D) Monitor urine output:
Monitoring urine output is an important aspect of postpartum care, but it is not the highest priority when the client is experiencing excessive bleeding. Addressing the potential cause of bleeding and preventing complications associated with postpartum hemorrhage take precedence.

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Correct Answer is A

Explanation

(D) "I might be experiencing preterm labor if walking stops my contractions."
Walking or changing positions may temporarily alleviate contractions in some cases, but this does not necessarily indicate preterm labor. In fact, true preterm labor contractions typically continue despite activity changes. Therefore, this statement does not demonstrate an accurate understanding of preterm labor signs.

A. "Wear an underwire bra between feedings." B. "You should use a breast pump if you plan to return to work." C. "Wash your nipples with soap and water daily." D. "Cover your breasts immediately after feedings."

Correct Answer is B

Explanation

(a) "Wear an underwire bra between feedings."
Wearing an underwire bra between feedings can compress breast tissue and impede milk flow, increasing the risk of mastitis. This recommendation is incorrect and could contribute to the development of mastitis rather than preventing it.

(b) "You should use a breast pump if you plan to return to work."
Regularly expressing breast milk with a breast pump, especially if planning to return to work, helps maintain milk supply and prevents engorgement, which can lead to mastitis. This recommendation encourages appropriate breastfeeding practices to prevent mastitis.

(c) "Wash your nipples with soap and water daily."
While maintaining good breast hygiene is important, excessive washing with soap and water can strip the nipples of natural oils and increase the risk of dryness and cracking, which may predispose to mastitis. This recommendation is not the most effective strategy for preventing mastitis.

(d) "Cover your breasts immediately after feedings."
Covering the breasts immediately after feedings may trap moisture and promote bacterial growth, increasing the risk of mastitis. It is important to allow the breasts to air dry after feedings to prevent moisture buildup and promote healing of any cracked nipples. This recommendation is not appropriate for preventing mastitis.

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A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes. Which of the following actions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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