A nurse is caring for a client 2 hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

Check the consistency of the client's uterine fundus.

Have the client use the bedpan to urinate.

Increase the client's ﬂuid intake.

Prepare to administer oxytocic medication.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Checking the consistency of the client's uterine fundus is the first action the nurse should take, as it can indicate the cause of excessive bleeding. A boggy or soft fundus indicates uterine atony, which is the most common cause of postpartum hemorrhage. The nurse should massage the fundus until it becomes firm and contracted.

Choice B reason:

Having the client use the bedpan to urinate is an important action, as a full bladder can displace the uterus and prevent it from contracting properly. However, this is not the first action the nurse should take, as it does not address the immediate source of bleeding.

Choice C reason:

Increasing the client's ﬂuid intake is an important action, as it can help replace ﬂuid loss and prevent hypovolemia and shock. However, this is not the first action the nurse should take, as it does not stop the bleeding.

Choice D reason:

Preparing to administer oxytocic medication is an important action, as it can stimulate uterine contractions and reduce bleeding. However, this is not the first action the nurse should take, as it requires a provider's prescription and may not be necessary if fundal massage is eﬀective.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Wear a nipple shield is incorrect, as this recommendation is not indicated for a client who has engorged breasts. A nipple shield is a thin, ﬂexible device that covers the nipple and areola and can help with latch problems, ﬂat or inverted nipples, or sore nipples. However, a nipple shield can also reduce milk transfer, stimulate less milk production, and cause nipple confusion or preference.

Choice B reason: Express milk from both breasts is correct, as this recommendation can help relieve engorgement and maintain milk production. Engorgement is a normal and expected phenomenon that occurs when the milk comes in, usually around 72 to 96 hr after birth. Engorgement can cause breast fullness, tenderness, warmth, and hardness. The nurse should advise the client to express milk from both breasts by breastfeeding frequently and eﬀectively or by using a breast pump or hand expression.

Choice C reason: Obtain a prescription for an antibiotic is incorrect, as this recommendation is not indicated for a client who has engorged breasts. An antibiotic is used to treat mastitis, which is an infection and inﬂammation of the breast tissue that can cause redness, pain, swelling, warmth, and fever in the aﬀected breast. The nurse should assess the client for signs of mastitis and report any abnormal findings to the provider.

Choice D reason: Apply a heating pad to her breasts is incorrect, as this recommendation can worsen engorgement and cause discomfort. A heating pad can increase blood ﬂow and swelling in the breasts, which can impair milk ﬂow and increase pain. The nurse should advise the client to apply cold compresses or cabbage leaves to her breasts to reduce inﬂammation and discomfort.

A. Position the client on her side. B. Elevate the client's legs. C. Administer oxygen via face mask. D. Increase the infusion rate of the IV ﬂuid.

Correct Answer is A

Explanation

Choice A reason: Position the client on her side is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Late decelerations are symmetrical decreases in the fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency and fetal hypoxia. Positioning the client on her side can improve blood ﬂow and oxygen delivery to the placenta and fetus by relieving pressure on the vena cava and aorta.

Choice B reason: Elevate the client's legs is incorrect, as this is not a priority action for a client who has late decelerations. Elevating the legs can increase venous return and cardiac output, but it can also reduce blood ﬂow and oxygen delivery to the placenta and fetus by compressing the vena cava and aorta.

Choice C reason: Administer oxygen via face mask is incorrect, as this is not the first action the nurse should take, although it is important to do later. Administering oxygen can increase oxygen saturation and delivery to the placenta and fetus, but it does not address the cause of uteroplacental insufficiency or improve blood ﬂow.

Choice D reason: Increase the infusion rate of the IV ﬂuid is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Increasing the infusion rate of IV ﬂuid can expand blood volume and improve placental perfusion, but it does not address the cause of uteroplacental insufficiency or improve blood ﬂow. The nurse should obtain a provider's order before increasing the IV ﬂuid rate.

View Question and Answer

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

A nurse is caring for a client 2 hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?

A nurse is caring for a client who is postpartum and asks, "When will my breast milk come in?" Which of the following responses should the nurse make?

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate eﬀectiveness of this medication?