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 A
Explanation
The nurse should maintain continuous observation of the adolescent.
Choice A reason:
The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.
Choice B reason:
Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.
Choice C reason:
Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.
Choice D reason:
Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.
Correct Answer is C
Explanation
"We allow our children the freedom to decide their own behavior.”
Choice A reason:
This statement does not indicate a permissive parenting style. In fact, it suggests an authoritative or authoritarian style, where the parents make decisions for their children without considering their input. The parents' imposition of their decisions on their children's time indicates a more controlling approach.
Choice B reason:
This statement also does not reflect a permissive parenting style. Instead, it represents an authoritative or authoritarian style, where the parents expect obedience and compliance without allowing room for questions or autonomy. This approach tends to be more structured and directive.
Choice C reason:
This statement demonstrates the use of a permissive parenting style. In permissive parenting, parents tend to be lenient and allow their children considerable freedom in decision-making and behavior. By giving their children the freedom to decide their own behavior, the parents are adopting a permissive approach, which can sometimes lead to indulgence and lack of necessary boundaries.
Choice D reason:
This statement does not indicate a permissive parenting style either. Instead, it suggests an authoritative or democratic style, where the parents explain the reasoning behind the rules they set. This approach encourages understanding and cooperation but is different from permissiveness.
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