A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period.
What should be the priority nursing intervention at this time?
Prepare to administer oxytocic medication.
Assist the client on a bedpan to urinate.
Palpate the client’s uterine fundus.
Increase the client’s fluid intake.
The Correct Answer is C
Choice A rationale
Administering oxytocic medication is an intervention that may be necessary if the client’s bleeding does not stop or if the uterus does not contract adequately. However, the priority is to assess the situation, which includes palpating the uterine fundus.
Choice B rationale
Assisting the client on a bedpan to urinate can help if the bladder is full and preventing the uterus from contracting properly. However, the priority is to assess the uterus by palpating the uterine fundus.
Choice C rationale
Palpating the client’s uterine fundus is the priority nursing intervention. A boggy uterus (one that does not contract properly) is a common cause of postpartum hemorrhage. If the uterus is not firm upon palpation, massage it until it firms up.
Choice D rationale
Increasing the client’s fluid intake can help replace lost fluids, but it is not the priority intervention. The first step is to assess the cause of the bleeding, which includes palpating the uterine fundus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Scheduling the procedure just before a menstrual flow is not necessary for a tubal ligation.
Choice B rationale
Tubal ligation does not typically reduce menstrual flow. In fact, some women may experience heavier periods after the procedure.
Choice C rationale
While some women may experience changes in their menstrual cycle after tubal ligation, it is not guaranteed that the procedure will lessen dysmenorrhea.
Choice D rationale
Tubal ligation is considered a permanent form of birth control. While reversal procedures exist, they are not always successful and should not be relied upon. Therefore, it is crucial for a woman to understand that she must think of the procedure as irreversible.
Correct Answer is ["0.42"]
Explanation
Step 1: Convert grams to milligrams: 3 g = 3000 mg Step 2: Find out how many milligrams are in each milliliter: 3000 mg ÷ 5 mL = 600 mg/mL Step 3: Calculate how many milliliters to administer for a 250 mg dose: 250 mg ÷ 600 mg/mL = 0.42 mL So, the nurse should administer
0.42 mL of the antibiotic per dose.
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