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
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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Related Questions
Correct Answer is B
Explanation
(A) Tell the client to apply hydrocortisone ointment to the affected area of the breast:
Hydrocortisone ointment is not appropriate for treating mastitis, which is an infection of the breast tissue. The primary treatments for mastitis include antibiotics, pain management, and supportive measures like warm compresses to relieve discomfort and promote milk flow.
(B) Suggest the client apply warm compresses to the affected breast:
Applying warm compresses to the affected breast can help relieve pain and promote milk flow, which can aid in resolving the infection. Warmth can help reduce inflammation and make breastfeeding or pumping less painful.
(C) Recommend the client avoid wearing a nursing bra until symptoms resolve:
Avoiding a nursing bra is not necessary. In fact, wearing a well-fitting and supportive nursing bra can help manage discomfort and support the breasts. It is important that the bra is not too tight to avoid further compression and blockage of milk ducts.
(D) Encourage the client to limit oral fluid intake to decrease milk production:
Limiting fluid intake is not recommended. Adequate hydration is important for overall health and maintaining milk supply. Reducing fluid intake does not effectively manage mastitis and can lead to dehydration.
Correct Answer is A
Explanation
(A) "You should recognize that your baby sucking on his hands is a hunger cue."
Recognizing hunger cues is crucial for successful breastfeeding. Early hunger cues like sucking on hands, rooting, and lip-smacking indicate that the baby is ready to feed. Responding to these cues can help establish a good breastfeeding routine and ensure the baby gets adequate nutrition before becoming too distressed to feed effectively.
(B) "You should feed your baby for 10 minutes on each breast."
Feeding duration can vary significantly among babies. Some may need longer than 10 minutes on each breast, while others might feed more efficiently in a shorter time. Instead of a strict time limit, it's important to encourage the mother to allow the baby to feed until they show signs of being full, such as pulling away from the breast or falling asleep.
(C) "You should feed your baby six times a day."
Newborns typically need to feed more frequently than six times a day. Most newborns breastfeed 8-12 times in 24 hours. Limiting feeds to six times a day may not provide sufficient nutrition and can affect the baby’s growth and milk supply.
(D) "You should wake your baby at least every 6 hours at night for feedings."
Newborns, especially in the first few weeks, often need to be fed more frequently than every 6 hours, including at night. Typically, it’s recommended to wake a baby to feed if they sleep for more than 4 hours at a time in the early weeks to ensure adequate intake and to help establish the mother’s milk supply.
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