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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale
While accidental lacerations can occur during a cesarean delivery, they are not typically the primary concern immediately after delivery.

Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a priority concern immediately after delivery.
Choice C rationale
Respiratory distress is a priority concern in a newborn after a cesarean delivery. Newborns delivered by cesarean may have transient tachypnea of the newborn (TTN), a condition characterized by rapid breathing during the first few hours of life.
Choice D rationale
While hypothermia is a concern in newborns, it is not typically the immediate priority following a cesarean delivery.

A. Left lower B. Right upper C. Left upper D. Right lower

Correct Answer is D

Explanation

Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on

the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn immediately after a scheduled cesarean delivery. Which of the following assessments should be the nurse’s priority?

Correct Answer is C

Explanation

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is D

Explanation

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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?