A nurse is caring for a client 2 hours following a spontaneous vaginal delivery and notes that the client has saturated
two perineal pads with blood in a 30-minute period.
Which of the following actions should the nurse take first?
Increase the client’s fluid intake
Check the consistency of the client’s uterine fundus
Help the client use the bedpan to urinate
Prepare to administer tocolytic medication
The Correct Answer is B
Choice A rationale:
Increasing fluid intake is not the priority action in this situation. While maintaining adequate hydration is important for
postpartum recovery, it does not directly address the immediate concern of excessive bleeding. Excessive fluid intake could
potentially worsen the bleeding by increasing blood volume and potentially increasing blood pressure.
Choice C rationale:
Helping the client use the bedpan to urinate is not the priority action in this case. While a full bladder can sometimes interfere
with uterine contraction and contribute to postpartum bleeding, it is not the most likely cause of the excessive bleeding in this
scenario. The client has already saturated two perineal pads in a short period, indicating a more significant bleeding issue that
needs to be addressed first.
Choice D rationale:
Preparing to administer tocolytic medication is not the appropriate action at this time. Tocolytic medications are used to stop
contractions, but they are not typically used to manage postpartum hemorrhage. In fact, tocolytics could potentially worsen
the bleeding by interfering with the natural mechanisms that help the uterus contract and stop bleeding after delivery.
Choice B rationale:
Checking the consistency of the client's uterine fundus is the priority action in this situation. The most common cause of
postpartum hemorrhage is uterine atony, which means the uterus is not contracting effectively to clamp down on the blood
vessels where the placenta was attached. A soft, boggy fundus is a sign of uterine atony. By assessing the fundus, the nurse can
quickly determine if uterine atony is the likely cause of the bleeding and take appropriate interventions to manage it.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Maintaining the client in the lithotomy position is not recommended during labor, particularly for extended periods.
It can impede blood flow, increase pressure on the sacral nerves, and potentially lead to discomfort, fatigue, and decreased
fetal oxygen supply.
It's essential to encourage position changes and ambulation during labor to promote comfort, fetal descent, and optimal blood
flow.
Choice B rationale:
Checking the client's temperature every 8 hours is not a priority intervention for a client in the active phase of labor following
an amniotomy.
While monitoring for infection is important, it's typically done more frequently, such as every 2-4 hours, if there are concerns
or risk factors.
More frequent temperature checks would be indicated if the client develops signs of infection, such as fever, chills, or foul-
smelling amniotic fluid.
Choice D rationale:
Reminding the client to bear down with each contraction is not appropriate during the active phase of labor.
Early bearing down can lead to maternal fatigue and potential complications like cervical lacerations, decreased fetal oxygen
supply, and perineal trauma.
It's generally recommended to encourage spontaneous pushing efforts when the client feels the urge to bear down, which
typically occurs during the second stage of labor when the cervix is fully dilated.
Choice C rationale:
Encouraging the client to empty the bladder every 2 hours is a crucial nursing intervention for a client in labor.
Here's why:
Preventing bladder distention: A full bladder can obstruct the fetal descent, prolong labor, and increase discomfort.
Promoting uterine contractions: An empty bladder allows more room for the uterus to contract effectively, facilitating labor
progress.
Reducing the risk of infection: Frequent bladder emptying helps prevent urinary tract infections, which can be more common
during labor due to catheterization or perineal trauma.
Enhancing comfort: A full bladder can cause significant pressure and discomfort for the laboring client. Emptying the bladder
regularly promotes relaxation and a sense of well-being.
Correct Answer is C
Explanation
Choice A rationale:
Amniotic fluid in the vaginal vault may indicate that the client's membranes have ruptured, but it does not necessarily mean
that labor has begun. Some women experience rupture of membranes before labor starts, while others do not experience it
until labor is well underway.
Additionally, it is not always possible to visually confirm the presence of amniotic fluid, as it may be mixed with other fluids or
present in small amounts.
Therefore, the presence of amniotic fluid alone is not a definitive sign of labor.
Choice B rationale:
Contractions are a common sign of labor, but they can also occur for other reasons, such as Braxton Hicks contractions or a
urinary tract infection.
To be considered a sign of true labor, contractions should be regular, becoming progressively stronger, longer, and closer
together.
A frequency of every 3 to 4 minutes is often suggestive of labor, but it is not always definitive.
Some women may experience contractions that are less frequent or more irregular and still be in labor.
Choice C rationale:
Cervical dilation is the most reliable sign of labor.
During labor, the cervix gradually opens to allow the baby to pass through the birth canal.
Cervical dilation is typically measured in centimeters, with 10 centimeters being considered full dilation.
Once the cervix has dilated to 3-4 centimeters, it is generally considered to be active labor.
This is because dilation of this degree usually indicates that the contractions are strong enough to effectively move the baby
through the birth canal.
Choice D rationale:
Pain just above the navel, also known as suprapubic pain, can be a sign of labor, but it is not a definitive one.
This type of pain can also be caused by other factors, such as bladder fullness or indigestion.
Additionally, not all women experience pain in this area during labor.
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