A nurse is caring for a 36-year-old female client in the labor and delivery unit at 39 weeks of gestation. The client has been admitted for evaluation of postpartum bleeding following a vaginal delivery of a viable newborn.
Select the 2 interventions the nurse should perform immediately.
Weigh the client’s perineal pad.
Insert a straight catheter for the client.
Administer methylergonovine 0.2 mg IM.
Draw a complete blood count.
Apply oxygen via nasal cannula.
Correct Answer : B,C
Choice A rationale: Weigh the client’s perineal pad: While weighing the perineal pad is helpful to estimate blood loss, it is not an immediate intervention that addresses the cause of the excessive bleeding or improves the client's condition in the moment.
Choice B rationale: Insert a straight catheter for the client: The client's fundus is deviated to the left and boggy, which can be due to a full bladder. Inserting a straight catheter can help empty the bladder, allowing the uterus to contract more effectively and reduce bleeding.
Choice C rationale: Administer methylergonovine 0.2 mg IM: Methylergonovine is a medication used to manage postpartum hemorrhage by stimulating uterine contractions. Given the client's excessive bleeding and boggy uterus, administering this medication can help improve uterine tone and reduce bleeding.
Choice D rationale: Draw a complete blood count: Drawing a complete blood count is useful for assessing the extent of blood loss and the client's overall condition, but it is not an immediate intervention that will directly address the excessive bleeding.
Choice E rationale: Apply oxygen via nasal cannula: Although oxygen can be beneficial for a client with significant blood loss to ensure adequate oxygenation, it does not directly address the cause of the excessive bleeding or improve uterine tone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Encouraging ambulation as often as possible helps to stimulate circulation and prevent the formation of blood clots in the legs, thereby reducing the risk of thrombophlebitis. Movement promotes venous return and prevents stasis, which is a primary factor in clot formation.
Choice B rationale
Warm, moist packs can provide comfort and relieve muscle tension but are not specifically effective in preventing thrombophlebitis. They do not promote circulation as effectively as ambulation.
Choice C rationale
Elastic stockings can be helpful in maintaining venous return but should be used alongside other measures like ambulation. They alone are insufficient to prevent thrombophlebitis if the client remains immobile.
Choice D rationale
NSAIDs can reduce inflammation and pain but do not specifically prevent thrombophlebitis. Regular movement and other preventive measures are necessary to effectively prevent blood clots.
Correct Answer is D
Explanation
Choice A rationale
Fasting is not required before a nonstress test. Clients are usually advised to eat and drink normally to ensure the baby is active during the test.
Choice B rationale
Medication to initiate contractions is not part of a nonstress test, which only monitors fetal heart rate and movements without inducing labor.
Choice C rationale
Lying flat on the back can cause discomfort and reduced blood flow to the uterus. Clients are typically positioned semi-reclined or in a side-lying position.
Choice D rationale
Pressing a button when the baby moves helps record the baby's movements and assess fetal well-being. It is a standard part of the nonstress test procedure.
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