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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Intermittent abdominal pain following passage of bloody mucus is more commonly associated with labor or conditions like bloody show but not specifically indicative of placenta previa.
Choice B rationale
Increasing abdominal pain with a non-relaxed uterus could be a sign of conditions such as uterine rupture or contractions, but it is not a typical sign of placenta previa. In placenta previa, the uterus is typically soft and non-tender.
Choice C rationale
Abdominal pain with scant red vaginal bleeding could be indicative of several conditions, including early labor or placental abruption, but it is not a typical sign of placenta previa. Placenta previa is usually characterized by painless bleeding.
Choice D rationale
Painless red vaginal bleeding is a classic sign of placenta previa. This occurs because the placenta, which is implanted low in the uterus, near or over the cervical os, begins to separate as the cervix effaces and dilates, leading to bleeding.
Correct Answer is B
Explanation
Choice A rationale
While excessive fatigue and headache can occur in pregnancy, they are not typically signs of labor.
Choice B rationale
A sudden gush of clear fluid from the vagina, also known as rupture of membranes, is a sign that labor may be starting.
Choice C rationale
Sharp, right-sided abdominal pain is not a typical sign of labor. It could indicate other issues such as appendicitis.
Choice D rationale
An increased pulse rate and upper abdominal pain are not typical signs of labor.
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