A nurse is assisting with the care of a client who is experiencing a postpartum hemorrhage. Which of the following actions should the nurse take? (Select all that apply.).
Firmly massage the fundus.
Administer oxygen via a nonrebreather face mask.
Ensure the client has IV access.
Prepare the client for an amnioinfusion.
Correct Answer : A,B,C,E
Choice A reason:
The nurse should firmly massage the fundus. The rationale behind this action is that massaging the fundus helps to stimulate uterine contractions, which aids in controlling bleeding after childbirth. By promoting uterine contractions, the nurse can assist in preventing further hemorrhage.
Choice B reason:
The nurse should administer oxygen via a nonrebreather face mask. The rationale for this action is that postpartum hemorrhage can lead to decreased oxygen levels in the blood, which can be detrimental to both the mother and the baby. Providing oxygen via a nonrebreather face mask ensures adequate oxygenation and helps stabilize the client's condition.
Choice C reason:
The nurse should ensure the client has IV access. Establishing IV access is crucial in managing postpartum hemorrhage as it allows for the rapid administration of fluids, blood products, and medications. IV access ensures that the client receives prompt treatment to address the blood loss and stabilize her condition.
Choice D reason:
The nurse should not prepare the client for an amnioinfusion in the context of postpartum hemorrhage. An amnioinfusion is a procedure used during labor to infuse fluid into the amniotic sac. However, it is not indicated or relevant in the management of postpartum hemorrhage.
Choice E reason:
The nurse should give the client Rh (D) immune globulin. The rationale behind this action is that Rh (D) immune globulin, also known as RhoGAM, is administered to Rh-negative mothers after the birth of an Rh-positive baby. This prevents the mother's immune system from developing antibodies against Rh-positive blood cells, which could cause complications in future pregnancies.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Take this medication every day for regular bowel movements. Rationale: This choice is incorrect. Docusate sodium is a stool softener used to prevent constipation, but it should not be taken daily for regular bowel movements. Overuse of stool softeners can lead to dependence and may disrupt the natural bowel function.
Choice B reason:
Take the medication with mineral oil. Rationale: This choice is incorrect. Docusate sodium should not be taken with mineral oil. When taken together, they can form a mixture that is difficult for the body to absorb, leading to potential adverse effects.
Choice C reason:
Decrease dietary fiber intake while taking this medication. Rationale: This choice is incorrect. It is not advisable to decrease dietary fiber intake while taking docusate sodium. Fiber is essential for promoting regular bowel movements and overall gastrointestinal health.
Combining the medication with a high-fiber diet can enhance its effectiveness.
Choice D reason:
Take the medication with a full glass of water. Rationale: This choice is correct. The nurse should instruct the client to take docusate sodium with a full glass of water. The water helps to soften the stool and allows the medication to work effectively in preventing constipation.
Correct Answer is D
Explanation
Choice D reason: The nurse should report the laboratory result of 2+ proteinuria (Choice D) to the healthcare provider. Proteinuria is the presence of excess protein in the urine, which can indicate a potential kidney problem or a complication related to pregnancy, such as preeclampsia. Preeclampsia is a serious condition characterized by high blood pressure and damage to organs like the liver and kidneys. Therefore, this result needs immediate attention to assess the client's condition properly and take appropriate actions to ensure the safety and well-being of both the mother and the baby.
Choice A reason:
The 2-hour postprandial glucose level of 105 mg/dL (Choice A) is within the normal range. During pregnancy, glucose levels are carefully monitored to check for gestational diabetes. In this case, the result falls within the acceptable range, indicating that the client's glucose levels are stable, and gestational diabetes is not a concern at this time.
Choice B reason:
A negative group B streptococcus (GBS) B-hemolytic result (Choice B) is actually a positive finding. It means that the client does not have an active infection with group B streptococcus, which is essential information for the management of labor and delivery. Therefore, there is no need to report this result to the provider as it indicates a favorable condition.
Choice C reason:
The hemoglobin (Hgb) level of 13 g/dL (Choice C) is within the normal range for a non- pregnant adult female. During pregnancy, blood volume increases, and hemoglobin levels can naturally decrease. However, the provided value is still within the acceptable range, indicating that the client's blood oxygen-carrying capacity is adequate and there is no immediate concern.
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