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 C
Explanation
Choice A reason:
Acrocyanosis (choice A) is a common and relatively normal finding in newborns, especially in the first few days of life. It refers to the bluish discoloration of the hands and feet due to peripheral vasoconstriction. Acrocyanosis alone does not necessarily indicate significant difficulty with oxygenation and is usually a transient and benign condition.
Choice B reason:
A respiratory rate of 54 breaths/minute (choice B) is within the normal range for a newborn. The normal respiratory rate for a newborn can range from 30 to 60 breaths per minute. While an abnormal respiratory rate outside this range may be a concern, a rate of 54 breaths/minute is not indicative of significant oxygenation difficulty by itself.
Choice C reason:
Nasal flaring in a newborn is a concerning sign that suggests the baby is experiencing difficulty with oxygenation. When a newborn is having trouble getting enough oxygen, they may instinctively open their nostrils wider (nasal flaring) to increase the airflow into the nose and improve oxygen intake. This is a compensatory mechanism to overcome respiratory distress and is often seen in newborns with respiratory problems. Nasal flaring is an important clinical sign that indicates the baby may be struggling to breathe adequately and requires further evaluation and intervention by the healthcare team.
Choice D reason:
Abdominal breathing (choice D) is a normal breathing pattern in newborns. Newborns predominantly use their diaphragm to breathe, which results in abdominal movements during respiration. This is a normal and expected finding in healthy newborns and does not necessarily suggest oxygenation problems.
Correct Answer is B
Explanation
Choice A reason:
Changing the patient's gown may be necessary for comfort and hygiene, but it is not the priority after an amniotomy. The main concern is the well-being of the fetus and the mother.
Choice B reason:
Assessing the fetal heart rate is the priority after an amniotomy. This procedure involves rupturing the amniotic sac, which may lead to changes in the fetal environment. Monitoring the fetal heart rate helps determine if the baby is tolerating the procedure well and if there are any signs of distress.
Choice C reason:
Estimating the amount of amniotic fluid is essential during an amniotomy, but it is not the top priority. The focus should be on evaluating the fetal well-being first.
Choice D reason:
Assessing the color of the amniotic fluid is significant, but it is not the primary concern immediately after an amniotomy. While changes in fluid color may indicate certain conditions, the fetal heart rate assessment takes precedence in this situation.
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.