A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
Assist the client on a bedpan to urinate.
Increase the client's fluid intake.
Palpate the client's uterine fundus.
Prepare to administer oxytocic medication.
The Correct Answer is C
Choice A reason:
Assisting the client on a bedpan to urinate is important for assessing urinary output and preventing bladder distension. However, in this situation, the priority is to assess and manage postpartum hemorrhage, which is indicated by the excessive bleeding.
Choice B reason:
Increasing the client's fluid intake is generally a good measure for promoting hydration and maintaining blood volume. However, it is not the priority in this scenario of excessive postpartum bleeding.
Choice C reason:
Palpating the client's uterine fundus is the priority nursing intervention at this time. The excessive bleeding indicated by saturating two perineal pads in a 30-minute period suggests postpartum hemorrhage, which can result from uterine atony (failure of the uterus to contract adequately after childbirth). Palpating the fundus allows the nurse to assess if the uterus is firm or boggy, and if it is not contracting properly, immediate interventions can be initiated to control the bleeding.
Choice D reason:
Preparing to administer oxytocic medication (such as oxytocin) can help stimulate uterine contractions and prevent or manage postpartum hemorrhage. However, the priority is to first assess the uterine fundus and confirm the cause of the excessive bleeding before administering any medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: a. Hyperbilirubinemia.
Choice A: Hyperbilirubinemia
Reason: Hyperbilirubinemia in newborns is often caused by the increased breakdown of red blood cells, which have a shorter lifespan in neonates. This breakdown produces bilirubin, a yellow pigment that can accumulate in the blood, leading to jaundice. The liver of a newborn is not fully mature and may not be able to process and excrete bilirubin efficiently, resulting in hyperbilirubinemia.
Choice B: Respiratory Distress Syndrome
Reason: Respiratory Distress Syndrome (RDS) is primarily caused by a deficiency of surfactant in the lungs, which is more common in premature infants. It is not directly related to the lifespan of red blood cells. Symptoms include rapid, shallow breathing and a bluish color due to lack of oxygen.
Choice C: Polycythemia
Reason: Polycythemia is characterized by an abnormally high concentration of red blood cells. It is often due to factors like delayed cord clamping or maternal diabetes, rather than the decreased lifespan of red blood cells. Polycythemia can lead to increased blood viscosity and complications such as sluggish blood flow.
Choice D: Transient Tachypnea
Reason: Transient Tachypnea of the Newborn (TTN) is a respiratory condition caused by delayed clearance of fetal lung fluid. It typically resolves within a few days and is not related to the lifespan of red blood cells. Symptoms include rapid breathing and grunting.
Correct Answer is []
Explanation
The diagram should be completed as follows:
Condition Most Likely Experiencing: B. Respiratory distress syndrome. Action to Take 1: C. Administer Surfactant as prescribed. Action to Take 2: Provide oxygen therapy as needed. Parameter to Monitor 1: B. Arterial blood gases. Parameter to Monitor 2: D. Oxygen saturation.
Conditions Explained
Choice A reason:
Hypoglycemia is a condition where the blood glucose level is too low. It can cause symptoms
such as jitteriness, lethargy, poor feeding, and seizures. However, hypoglycemia does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of hypoglycemia. Therefore,
choice A is incorrect.
Choice B reason:
Respiratory distress syndrome (RDS) is a condition where the lungs are not fully developed
and lack enough surfactant, a substance that helps the alveoli stay open and exchange
oxygen and carbon dioxide. It can cause symptoms such as tachypnea, grunting, nasal flaring,
retractions, and cyanosis. RDS is more common in premature infants, especially those born
before 37 weeks of gestation. Acrocyanosis can be a normal finding in the first 24 hours of
life, but it can also indicate poor perfusion due to respiratory compromise. Therefore, choice
B is the most likely condition that the newborn is experiencing.
Choice C reason:
Neonatal abstinence syndrome (NAS) is a condition where the newborn withdraws from
drugs that were exposed in utero. It can cause symptoms such as irritability, tremors, high-
pitched crying, poor feeding, vomiting, diarrhea, and sweating. However, NAS does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of NAS. Therefore, choice C is
incorrect.
Choice D reason:
Jaundice is a condition where the skin and sclerae turn yellow due to excess bilirubin in the
blood. It can be caused by various factors such as blood group incompatibility, hemolysis,
infection, or liver dysfunction. However, jaundice does not explain the respiratory signs that
the newborn is experiencing, such as tachypnea, grunting, nasal flaring, and retractions.
Acrocyanosis is also not a sign of jaundice.
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.