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.
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Correct Answer is D
Explanation
Choice A reason:
A prolapsed umbilical cord occurs when the cord slips ahead of the presenting fetal part, potentially leading to cord compression and compromised fetal oxygenation. However, hypertonic contractions do not directly cause a prolapsed cord. Instead, factors such as premature rupture of membranes, abnormal fetal positioning, or excessive amniotic fluid (polyhydramnios) are more likely contributors to cord prolapse. Hypertonic contractions primarily affect uteroplacental circulation rather than fetal positioning.
Choice B reason:
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it produces a prolapsed cord. This is incorrect because a prolapsed cord is not caused by hypertonic contractions, but by other factors such as a low-lying placenta, a premature rupture of membranes, a small or preterm fetus, or an abnormal presentation. A prolapsed cord occurs when the umbilical cord slips through the cervix and into the vagina before or during delivery. This can compress the cord and cut off the blood supply to the fetus, resulting in fetal bradycardia and possible death.
Choice C reason:
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it increases maternal renal blood flow. This is incorrect because hypertonic contractions do not affect maternal renal blood flow directly. Maternal renal blood flow is influenced by factors such as maternal blood pressure, hydration, cardiac output, and renal function. Hypertonic contractions may cause maternal dehydration, which can reduce renal blood flow, but this is not a direct effect of oxytocin stimulation.
Choice D reason:
Hypertonic contractions reduce placental blood flow by limiting the relaxation phase between contractions. Normally, uterine contractions intermittently compress the spiral arteries supplying the placenta, but prolonged or excessively frequent contractions prevent adequate placental perfusion. This can lead to fetal hypoxia, acidosis, and distress, making it the most detrimental effect of oxytocin-induced hypertonic contractions.
Correct Answer is B
Explanation
Choice A reason:
Choice A is incorrect because an Apgar score of 7 would not be appropriate for the described condition. An Apgar score of 7-10 is considered normal for a baby at 1 minute after birth. This baby shows positive signs such as a heart rate of 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet, which indicate good overall health.
Choice B reason:
Choice B is the correct answer. An Apgar score of 8 is appropriate for the described condition.
The Apgar score evaluates the baby's condition at 1 minute after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criterion is scored from 0 to 2, and the scores are summed up to determine the overall Apgar score. In this case, the baby exhibits positive signs in most of the criteria, resulting in an Apgar score of 8.
Choice C reason:
Choice C is incorrect because an Apgar score of 9 would be too high for the baby's condition. While the baby is exhibiting positive signs, there are still some concerns such as the bluish color of the hands and feet, which may indicate some minor circulation issues.
Choice D reason:
Choice D is also incorrect because an Apgar score of 10 is the highest possible score, and it is typically given to babies who exhibit absolutely no signs of distress or health issues at 1 minute after birth. While this baby shows mostly positive signs, the bluish color of the hands and feet suggests that there might be some minor health concerns, justifying an Apgar score of 8.
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