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 question is about a client who has been in the latent phase of labor for 12 hours and wants some medication to help her rest. The nurse has to predict which medication the healthcare provider will prescribe. The choices are:. • A. Fentanyl: a synthetic opioid that is used for pain relief and sedation. It is fast-acting and potent, but can cause respiratory depression and nausea. • B. Meperidine: a synthetic opioid that is used for pain relief and sedation. It is less potent than fentanyl, but can cause seizures and serotonin syndrome. • C. Morphine: a natural opioid that is used for pain relief and sedation. It is less potent than fentanyl, but can cause respiratory depression and itching. • D. Secobarbital: a barbiturate that is used for sedation and anesthesia. It is not an opioid, but can cause respiratory depression and addiction.
Correct Answer is A
Explanation
Choice A reason:
Babinski's Reflex is the normal response in infants when the sole of the foot is stroked from the heel to the ball of the foot. The big toe moves upward or toward the top surface of the foot, and the other toes fan out. This reflex is normal in children up to 2 years old, and it disappears as the nervous system matures. It may indicate damage to the central nervous system in older children and adults.
Choice B reason:
Stepping Reflex is the normal response in infants when they are held upright with their feet touching a flat surface. They will lift one foot and then the other, as if they are walking. This reflex is present at birth and lasts for about 2 months. It helps prepare the infant for voluntary walking.
Choice C reason:
Moro Reflex is the normal response in infants when they are startled by a loud noise or a sudden movement. They will extend their arms and legs, open their hands, and then curl up and bring their arms together as if they are hugging themselves. This reflex is present at birth and lasts for about 4 to 6 months. It is thought to be a protective response that helps the infant cling to their caregiver.
Choice D reason:
Plantar Grasp Reflex is the normal response in infants when pressure is applied to the sole of the foot near the toes. The toes will curl down and grasp the stimulus. This reflex is present at birth and lasts for about 9 to 12 months. It is similar to the palmar grasp reflex in the hands, and it helps develop the muscles and nerves in the feet. Some additional sentences are:. If you are interested in learning more about infant development, you can check out some of these links:. • [A guide to newborn reflexes]. • [A video demonstration of newborn reflexes].
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