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 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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.
Choice B reason:
Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.
Choice C reason:
Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.
Choice D reason:
Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.
Correct Answer is A
Explanation
Choice A rationale:
This finding may indicate a neurological problem or an issue with the baby's ability to feed, which can lead to inadequate nutrition and hydration. It's essential for the newborn to establish good feeding patterns early on
Choice B rationale:
Blue coloring of the hands and feet, also known as acrocyanosis, is a common and normal finding in newborns. It results from the immaturity of the peripheral circulation and usually resolves on its own without any intervention.
Choice C rationale:
A soft, edematous area on the scalp, also known as caput succedaneum, is a common finding following vacuum-assisted delivery and typically resolves without intervention.
Choice D rationale:
Facial edema is another common finding in newborns, especially after vacuum-assisted deliveries. It is typically a transient and self-resolving condition that does not require immediate intervention or reporting to the provider.
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