A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Palpate the client's uterine fundus.

Assist the client on a bedpan to urinate.

Prepare to administer oxytocic medication.

Increase the client's fluid intake.

Answer and Explanation

The Correct Answer is A

A. Palpating the client's uterine fundus is the priority intervention because excessive postpartum bleeding could indicate uterine atony, where the uterus fails to contract effectively. Assessing the fundus will help determine if it is boggy and if fundal massage is needed to promote uterine contraction and reduce bleeding.

B. Assisting the client to urinate is an important intervention if the bladder is distended, as a full bladder can prevent the uterus from contracting properly. However, palpating the fundus to assess the source of bleeding takes priority over assisting with urination.

C. Preparing to administer oxytocic medication may be necessary if the uterine fundus is boggy and does not respond to massage, but the first step is to assess the fundus and attempt manual intervention before proceeding with medication.

D. Increasing the client's fluid intake can help maintain circulation and prevent dehydration, but it does not address the immediate concern of postpartum hemorrhage. Palpating the fundus is the priority action in this scenario

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Correct Answer is A

Explanation

Choice A rationale:

Cesarean birth is a factor strongly associated with postpartum deep-vein thrombosis (DVT) After a cesarean section, the risk of developing DVT increases due to reduced mobility and potential trauma to blood vessels during the surgery. Decreased mobility can lead to blood stasis, increasing the risk of clot formation.

Choice B rationale:

Rheumatoid arthritis (Choice B) is not directly associated with an increased risk of postpartum DVT. Other autoimmune disorders, such as antiphospholipid syndrome, may be associated with a higher risk of DVT, but rheumatoid arthritis itself is not a known risk factor.

Choice C rationale:

Hypotension (Choice C) is not directly linked to an increased risk of postpartum DVT. However, hypotension can be associated with other complications and should be managed appropriately.

Choice D rationale:

Uterine atony (Choice D) is excessive bleeding following childbirth due to the uterus not contracting adequately. While it is a postpartum complication, it is not directly associated with an increased risk of DVT.

A. Decrease dietary fiber. B. Practice Kegel exercises. C. Restrict daily fluid intake. D. Reduce caffeine intake. E. Avoid daily exercise.

Correct Answer is ["B","D"]

Explanation

Choice A rationale:

This would be incorrect advice. Increasing dietary fiber is commonly recommended during pregnancy to prevent constipation, but it does not address stress incontinence.

Choice B rationale:

This is a correct choice. Kegel exercises are beneficial during pregnancy to strengthen the pelvic floor muscles, which can help manage stress incontinence.

Choice C rationale:

This would be incorrect advice. Restricting daily fluid intake during pregnancy is generally not recommended as it can lead to dehydration and is unlikely to improve stress incontinence.

Choice D rationale:

This is another correct choice. Caffeine is a bladder irritant and can worsen stress incontinence, so reducing caffeine intake can be helpful.

Choice E rationale:

This would be incorrect advice. Regular exercise during pregnancy is generally encouraged unless there are specific medical reasons to avoid it. Avoiding daily exercise is not the appropriate approach to manage stress incontinence.

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A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who is at 32 weeks of gestation and is experiencing stress incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

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