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.
The Correct Answer is C
Choice A rationale:
Palpating the client's uterine fundus is an essential nursing intervention after childbirth to assess for uterine atony or excessive bleeding. However, in this scenario, the client has already saturated two perineal pads with blood in a short period, indicating active bleeding. Therefore, the priority is to take immediate action to stop the bleeding, rather than assessing the uterine fundus.
Choice B rationale:
Assisting the client on a bedpan to urinate is important for postpartum care and can help prevent bladder distension and discomfort. However, it is not the priority in this situation where the client is experiencing significant postpartum bleeding. Managing the bleeding is the primary concern at this time.
Choice C rationale:
The correct priority nursing intervention is to prepare to administer oxytocic medication. Oxytocic drugs, such as oxytocin (Pitocin), are used to stimulate uterine contractions and prevent or treat postpartum hemorrhage. Administering this medication promptly can help control the bleeding and prevent further complications.
Choice D rationale:
Increasing the client's fluid intake may be beneficial for postpartum hydration, especially if the client has lost a significant amount of blood. However, it is not the priority in this situation. Managing the postpartum bleeding takes precedence, and if intravenous fluids are needed, they can be given concurrently with the administration of oxytocic medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.
Choice B rationale:
This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.
Choice C rationale:
Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.
Choice D rationale:
Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should discontinue the oxytocin infusion if the client's contraction frequency is every 3 minutes. Frequent contractions may lead to uterine hyperstimulation, which can reduce fetal blood flow and oxygenation, potentially causing fetal distress. Normal contraction frequency during labor is typically every 2 to 5 minutes.
Choice B rationale:
Contraction duration of 100 seconds is not an indication to discontinue the oxytocin infusion. The duration of contractions can vary during labor, and 100 seconds is within the normal range of contraction duration, which is usually 45 to 90 seconds.
Choice C rationale:
Fetal heart rate with moderate variability is not an indication to discontinue the oxytocin infusion. Moderate variability in fetal heart rate is a reassuring sign, indicating a healthy fetal response to labor. It shows that the fetus is tolerating the contractions well and is not experiencing fetal distress.
Choice D rationale:
A fetal heart rate of 118/min is not an indication to discontinue the oxytocin infusion. The normal fetal heart rate range is typically between 110 to 160 beats per minute, and a heart rate of 118/min falls within this normal range. However, if the fetal heart rate deviates significantly from the normal range or shows signs of distress, further assessment and intervention are required.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.