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

(A) "You will be prescribed methadone":
Methadone maintenance therapy is a commonly used treatment for opioid use disorder in pregnant women. Methadone helps to manage withdrawal symptoms, reduce cravings, and stabilize the individual, promoting healthier outcomes for both the mother and the baby.

(B) "You will be prescribed aripiprazole":
Aripiprazole is not typically prescribed for opioid use disorder. It is an antipsychotic medication used to treat conditions such as schizophrenia, bipolar disorder, and depression, but it is not indicated for opioid dependence or withdrawal.

(C) "You will be prescribed naloxone":
Naloxone is an opioid antagonist used to reverse opioid overdose. While it is crucial to have naloxone readily available for individuals with opioid use disorder to prevent overdose deaths, it is not a primary treatment for opioid use disorder during pregnancy.

(D) "You will be prescribed diazepam":
Diazepam is a benzodiazepine medication primarily used for anxiety, muscle spasms, and seizures. It is not indicated for the treatment of opioid use disorder during pregnancy. In fact, benzodiazepines like diazepam should be used with caution during pregnancy due to the risk of birth defects and neonatal withdrawal symptoms.

A. Perform unbiased teaching B. Assess the client's socioeconomic status C. Collect a dietary history D. Select the best method of contraception for the client.

Correct Answer is A

Explanation

(A) Perform unbiased teaching:
The nurse should provide comprehensive and unbiased information about the various methods of contraception available. This involves explaining the pros and cons of each method, effectiveness, potential side effects, and how each method aligns with the client's lifestyle and health needs, allowing the client to make an informed decision.

(B) Assess the client's socioeconomic status:
While understanding the client's socioeconomic status can provide context for their healthcare needs and potential barriers to accessing certain types of contraception, it is not the primary action when inquiring about contraception methods. The focus should be on providing unbiased information first.

(C) Collect a dietary history:
Collecting a dietary history is not directly relevant to discussing contraception methods. While nutritional status is important for overall health, it does not significantly impact the choice of contraception.

(D) Select the best method of contraception for the client:
The nurse should not select the contraception method for the client. Instead, the nurse's role is to provide the necessary information and support for the client to make their own informed choice. Autonomy and personal preference are key factors in selecting a contraception method.

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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

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