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.).

Birth weight has doubled.

Choice A reason:

The nurse should not expect a positive Babinski sign in a 4-year-old child during a well-child visit. The Babinski sign is a reflex seen in infants up to about 1 year of age and disappears as the nervous system matures. Its presence in a 4-year-old would be abnormal and may indicate neurological issues.

Choice B reason:

The nurse should not expect birth height to double in a 4-year-old child during a well-child visit. While children do experience significant growth in their early years, it is unlikely that birth height will have doubled by the age of 4. Doubling of birth height would be an atypical finding.

Choice C reason:

The correct choice. The nurse should expect that the child's birth weight has doubled during a well-child visit. From birth to age 4, children typically experience substantial weight gain, and doubling of birth weight is a common milestone in healthy development.

Choice D reason:

The nurse should not expect the presence of permanent teeth in a 4-year-old child during a well-child visit. Permanent teeth typically begin to emerge around 6 years of age and continue to erupt over the following years. The appearance of permanent teeth at age 4 would be premature and unusual.

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.