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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Position the client on her left side is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Positioning the client on her left side can enhance uterine blood flow and placental perfusion, but it does not address the cause of uterine atony or bladder distension.
Choice B reason: Encourage the client to perform Kegel exercises is incorrect, as this action is not indicated for a client who has a boggy and displaced fundus. Kegel exercises can strengthen the pelvic floor muscles and prevent urinary incontinence, but they do not affect the uterine tone or position.
Choice C reason: Ask the client to rate her pain is incorrect, as this action is not a priority for a client who has a boggy and displaced fundus. Asking the client to rate her pain can provide information about the need for analgesics, but it does not address the risk of hemorrhage or infection due to uterine atony or bladder distension.
Choice D reason: Assist the client to the bathroom to void is correct, as this action can resolve the problem of a boggy and displaced fundus. A boggy and displaced fundus indicates uterine atony and bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and then massage the fundus until it becomes firm and midline.
Correct Answer is B
Explanation
Choice A reason: Apply warm, moist soaks to the client's lower legs is incorrect, as this action is not effective for preventing thrombophlebitis. Warm, moist soaks can provide comfort and reduce inflammation, but they do not improve blood circulation or prevent clot formation.
Choice B reason: Have the client ambulate frequently in the hallway is correct, as this action can prevent thrombophlebitis by improving venous return and preventing stasis. The nurse should encourage and assist the client to ambulate early and frequently after a cesarean birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice C reason: Keep the client on bed rest is incorrect, as this action can increase the risk of thrombophlebitis by reducing blood flow and promoting stasis. Bed rest can also delay wound healing and increase the risk of infection and deconditioning. The nurse should avoid keeping the client on bed rest unless absolutely necessary.
Choice D reason: Place pillows under the client's knees while she is resting in bed is incorrect, as this action can impair blood circulation and increase the risk of thrombophlebitis. Placing pillows under the knees can cause pressure on the popliteal veins and reduce venous return. The nurse should advise the client to avoid crossing their legs or placing pillows under their knees while resting in bed.
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