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 A
Explanation
Choice A rationale
Late decelerations on the fetal monitor are a sign of fetal hypoxia, which means the baby is not getting enough oxygen. The priority nursing action is to position the client on her side, preferably the left side. This position improves blood flow to the uterus and the baby, potentially improving oxygenation.
Choice B rationale
Administering oxygen via face mask can also improve fetal oxygenation, but it is not the first action the nurse should take. Repositioning the client is a quicker intervention and often resolves the issue.
Choice C rationale
Elevating the client’s legs will not improve fetal oxygenation and is not a priority action when late decelerations are noted on the fetal monitor.
Choice D rationale
Increasing the infusion rate of the IV fluid can improve maternal blood volume and cardiac output, potentially improving blood flow to the uterus and the baby. However, it is not the first action the nurse should take when late decelerations are noted.
Correct Answer is B
Explanation
Choice A rationale
The deltoid muscle is not typically used for intramuscular injections in infants due to its small size.
Choice B rationale
The vastus lateralis muscle is one of the preferred sites for intramuscular injections in infants, including the vitamin K injection. This muscle is large enough to absorb the medication, and injections here carry less risk of hitting a nerve or blood vessel.
Choice C rationale
The ventrogluteal muscle is not typically used for intramuscular injections in infants. This site is often used in older children and adults.
Choice D rationale
The dorsogluteal site is not recommended for intramuscular injections due to the risk of damaging the sciatic nerve.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.