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:

The client's statement, "I will check the identification badge of anyone who removes my baby from our room,” indicates an understanding of newborn safety. This statement shows the client's awareness of the importance of verifying the identity of anyone handling their baby before allowing them to be taken out of the room. Checking identification badges helps ensure that only authorized personnel, such as nurses or hospital staff, are allowed to handle the newborn, reducing the risk of unauthorized individuals taking the baby.

Choice B rationale:

This statement is incorrect and does not demonstrate an understanding of newborn safety. Including a photo of the baby along with public birth announcements to social media can compromise the baby's security and privacy. It may expose sensitive information about the baby's location and identity, making the baby vulnerable to potential risks.

Choice C rationale:

This statement is incorrect as it poses a safety risk to the newborn. Allowing the baby to sleep on the bed when the client is in the shower increases the risk of falls or suffocation. The baby should always be placed in a safe sleep environment, such as a crib or bassinet, to minimize the risk of accidents.

Choice D rationale:

This statement is incorrect and does not reflect an understanding of newborn safety. Nurses should not carry the baby in their arms to the nursery. Instead, they should use a crib or an infant carrier to transport the baby safely.

A. Peanut butter sandwich on wheat bread. B. A sliced apple and red grapes. C. A chocolate chip cookie with a glass of skim milk. D. A scrambled egg with cheddar cheese.

Correct Answer is B

Explanation

A. Peanut butter and wheat bread contain high levels of phenylalanine, which should be avoided in clients with phenylketonuria.
B. A sliced apple and red grapes are low in phenylalanine and are safe choices for a client with phenylketonuria.
C. Chocolate, cookies, and milk contain phenylalanine, making them unsuitable for the client.
D. Eggs and cheese are high in phenylalanine and should be restricted in the diet.

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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 nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?

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