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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Normal progression of labor: After the fetal head is delivered, the shoulders typically follow immediately. The nurse should be prepared to assist with the delivery of the shoulders to ensure a safe and smooth birth process.
Significance of retraction: Retraction of the fetal head against the maternal perineum, also known as the "turtle sign," is a classic indicator of shoulder dystocia. While this sign does not guarantee shoulder dystocia, it warrants immediate preparation for potential management.
Anticipating shoulder dystocia: By anticipating the possibility of shoulder dystocia, the nurse can take proactive measures to minimize risks and facilitate delivery. These measures may include:
Positioning the mother appropriately (e.g., McRoberts maneuver)
- Applying suprapubic pressure
- Performing internal maneuvers (e.g., Rubin's maneuver)
- Breaking the clavicle (in extreme cases)
Choice B rationale:
Ineffective in shoulder dystocia: Encouraging the mother to push during the next contraction is not an effective intervention
for shoulder dystocia. In fact, excessive pushing can worsen the impaction of the shoulders and potentially lead to
complications such as fetal hypoxia, brachial plexus injury, or maternal perineal trauma.
Choice C rationale:
Necessary in confirmed dystocia: Calling for additional medical support is crucial if shoulder dystocia is confirmed. However,
immediate preparation for shoulder delivery should commence without delay, as prompt action is essential to prevent adverse
outcomes.
Choice D rationale:
Secondary concern: While pain relief medication may be administered for maternal comfort, it is not a priority intervention in
this situation. The primary focus should be on managing the potential shoulder dystocia and ensuring the safe delivery of the
baby.
Correct Answer is A
Explanation
Choice A rationale:
Uterine atony is the most common cause of postpartum hemorrhage, and it is characterized by a lack of uterine muscle tone,
which leads to excessive bleeding after delivery.
A macrosomic newborn (weighing over 4000 g) is a significant risk factor for uterine atony because the overdistention of the
uterus during pregnancy can impair its ability to contract effectively after delivery.
Other risk factors for uterine atony include prolonged labor, multiple gestations, rapid labor, use of oxytocin or magnesium
sulfate during labor, and a history of uterine atony in previous deliveries.
It's crucial for a nurse to closely monitor clients with these risk factors for signs of uterine atony, such as excessive vaginal
bleeding, a soft and boggy uterus, and a rising fundus.
Prompt recognition and management of uterine atony are essential to prevent life-threatening hemorrhage.
Choice B rationale:
Retained placental fragments can also contribute to postpartum hemorrhage; however, they are not as strongly associated
with macrosomia as uterine atony.
Risk factors for retained placental fragments include premature separation of the placenta, placenta accreta, and manual
removal of the placenta.
Choice C rationale:
Thrombophlebitis, a blood clot formation in a vein, is a postpartum complication, but it's not directly related to macrosomia.
Risk factors for thrombophlebitis include venous stasis, hypercoagulability, and trauma to the veins, such as from prolonged
bed rest or cesarean delivery.
Choice D rationale:
Perineal infection is also a potential postpartum complication, but it's not specifically linked to macrosomia.
Risk factors for perineal infection include perineal lacerations, episiotomy, and poor hygiene.
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