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:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.

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 client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

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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