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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:

Placing a covering on the scale tray when weighing an infant helps to ensure that conductive heat loss from the infant is minimal. Newborns and infants are especially vulnerable to temperature changes, and maintaining their body temperature is crucial for their well-being. By placing a covering, such as a soft cloth or blanket, on the scale tray, the nurse creates a barrier between the infant's skin and the cold surface of the scale. This reduces the risk of heat loss from direct contact with the scale, helping to keep the baby comfortable and preventing any potential adverse effects from exposure to low temperatures during the weighing process.

Choice B reason:

Choice B, compensating for the negative weight balance to ensure the correct weight, is not the primary reason for using a covering on the scale tray. The negative weight balance, if any, would be minimal and not significant enough to affect the accuracy of the infant's weight measurement. The main concern when using a scale for weighing infants is to ensure their comfort and safety during the process.

Choice C reason:

Choice C, avoiding causing multiple startle (Moro) reflexes when weighing, is not the main reason for using a covering on the scale tray. The Moro reflex is a normal startle response in infants and is not typically affected by whether or not a covering is placed on the scale tray.

The nurse can support the infant appropriately during weighing to minimize any startle reflexes, regardless of whether a covering is used.

Choice D reason:

Choice D, avoiding contaminating the nurse's hands with blood or other body substances, is not directly related to using a covering on the scale tray. The primary purpose of using a covering is to minimize heat loss, as explained in Choice A. However, it is standard practice for healthcare professionals to wear gloves when handling blood or body substances to prevent any potential transmission of infections, ensuring both the nurse's and the infant's safety.

A. Place a cool cloth on her forehead and dim the room lights. B. Prepare to assist with a blood patch procedure. C. Increase the rate of her nonadditive IV fluids. D. Give the woman IV opioid pain medications.

Correct Answer is B

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The correct answer is choice A, which is to ensure that conductive heat loss from the infant is minimal

Correct Answer is A

Explanation

A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate?

Correct Answer is B

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