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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Adolescents tend to believe their own actions might have caused their terminal illness. Choice A reason:
This statement reflects a common developmental focus for adolescents, who are often navigating issues related to identity and self-image. While they are aware of their illness, many may prioritize concerns about how they look and how they are perceived by others. This can be a significant aspect of their experience during a terminal illness.
Choice B reason:
Many adolescents imagine death as a type of monster. Although this statement acknowledges a common perception of death among some adolescents, it is not the best choice for reinforcing teaching about the perception of death in the context of a terminal illness. The focus should be on more concrete and realistic aspects of death and its implications.
Choice C reason:
This statement does reflect a valid concern but may not be as prevalent as the concern with appearance in this age group. Many adolescents, especially in a terminal situation, may focus on more immediate concerns, such as how they are perceived.
Choice D reason:
Many adolescents don't understand that death is permanent. While this statement may be true for some adolescents who are still developing a full comprehension of death, it is not the most suitable choice for this scenario. In the context of a terminal illness, it is essential to acknowledge that the adolescent likely has a clear understanding of the finality of death.
Correct Answer is D
Explanation
Choice A reason:
The nurse should not tell the client to lie flat on their back for the duration of the nonstress test. It is essential for pregnant clients to be in a semi-reclining or left lateral position during the test to avoid supine hypotension syndrome. This condition can occur when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and potentially compromising the baby's well-being.
Choice B reason:
The nurse should not instruct the client to lightly brush their palms across their nipples during the test. This statement is not related to the nonstress test procedure. The nonstress test involves monitoring the baby's heart rate in response to its movements, and nipple stimulation is not a standard part of the test.
Choice C reason:
The nurse should not advise the client not to eat or drink anything for 4 hours before the test. It is important for pregnant clients to have adequate nutrition and hydration, especially during the third trimester. Restricting food and drink for such a prolonged period could lead to dehydration and may not be necessary for the test.
Choice D reason:
This is the correct choice. During a nonstress test, the client is connected to a fetal heart rate monitor. They are asked to press a button whenever they feel the baby moving. This allows the healthcare provider to correlate the baby's movements with changes in the heart rate pattern, which helps assess the baby's well-being.
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