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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The woman had a vacuum-assisted birth. While vacuum-assisted births can cause perineal trauma, the specific orders for ice packs, sitz baths, and stool softeners are more directly related to an episiotomy, which involves a surgical incision that requires careful postpartum care.
B. The woman is a gravida 2, para 2. This information indicates the woman's obstetric history but does not directly correlate with the need for perineal ice packs, sitz baths, and stool softeners. These orders are more specific to perineal trauma or surgical intervention.
C. The woman has an episiotomy. An episiotomy involves a surgical cut made at the opening of the vagina during childbirth, which can cause significant perineal pain and swelling. The orders for perineal ice packs, sitz baths, and stool softeners are intended to manage pain, reduce swelling, and prevent constipation, which can be particularly uncomfortable with perineal stitches.
D. The woman received epidural anesthesia. While epidural anesthesia is a common pain management technique during labor, it does not necessitate the use of perineal ice packs, sitz baths, or stool softeners postpartum. These orders are more indicative of perineal trauma or surgical intervention such as an episiotomy.
Correct Answer is A
Explanation
Choice A reason:
Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.
Choice B reason:
Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.
Choice C reason:
Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.
Choice D reason:
Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.
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