A nurse is caring for a client 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following is the nurse's first action?

Observe for pooling of blood under the butocks.

Assess client's blood pressure.

Prepare to administer a prescribed oxytocic preparation.

Massage the client's fundus.

Answer and Explanation

The Correct Answer is D

The nurse's first action should be to massage the client's fundus, as this can help stimulate uterine contraction and prevent hemorrhage. The fundus is the upper part of the uterus that contracts and involutes after delivery to compress the blood vessels and stop bleeding. The nurse should palpate the fundus for firmness, height, and position, and massage it gently if it is boggy or displaced.

The other actions are not the first priority and may be done after massaging the fundus.

The nurse should observe for the pooling of blood under the buttocks, as this can indicate a large amount of blood loss that may not be visible on the perineal pad. However, this is not the first action to take, as it does not address the cause of the bleeding or stop it from continuing.

The nurse should assess the client's blood pressure, as this can indicate the severity of blood loss and the presence of shock. However, blood pressure may not change significantly until a large amount of blood is lost, and it is not specific to the cause of bleeding. Therefore, blood pressure is not the first action to take.

The nurse should prepare to administer a prescribed oxytocic preparation, such as oxytocin or methylergonovine, as this can enhance uterine contraction and reduce bleeding. However, this requires a provider's order and may take time to obtain and administer. Therefore, an oxytocic preparation is not the first action to take.

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Correct Answer is C

Explanation

c. Excessive uterine enlargement

A hydatidiform mole is a type of gestational trophoblastic disease, where the placenta develops abnormally into a mass of cysts that resemble grape-like clusters. A hydatidiform mole can cause excessive uterine enlargement, as the uterus grows larger than expected for the gestational age. The nurse should measure the fundal height and compare it with the expected value based on the last menstrual period or ultrasound.

The other findings are not associated with a hydatidiform mole and may indicate other conditions.

Whitish vaginal discharge is not a sign of a hydatidiform mole, but it may be normal in pregnancy due to increased cervical mucus production. However, if the discharge is foul-smelling, yellow, green, or bloody, it may indicate an infection or a complication such as preterm labor or placental abruption.

Fetal heart rate irregularities are not a sign of a hydatidiform mole, but they may indicate fetal distress or congenital anomalies. A hydatidiform mole usually does not have a viable fetus, and fetal heart tones are absent or very faint. The nurse should use a Doppler device or a fetal monitor to assess the fetal heart rate and rhythm.

d. Rapidly dropping human chorionic gonadotropin (hCG) levels are not a sign of a hydatidiform mole, but they may indicate a spontaneous abortion or an ectopic pregnancy. A hydatidiform mole usually causes very high hCG levels, as the abnormal placental tissue secretes large amounts of this hormone. The nurse should perform a urine or blood test to measure the hCG levels and monitor them for chan

A. Measure the client's vital signs. B. Check the client's fundus. C. Feel for a full bladder. D. Request the provider perform a vaginal examination.

Correct Answer is B

Explanation

The nurse should check the client's fundus first, as this is the most likely source of bleeding and clots in the postpartum period. The fundus is the upper part of the uterus that contracts and involutes after delivery to prevent hemorrhage. The nurse should palpate the fundus for firmness, height, and position, and massage it gently if it is boggy or displaced. A soft, high, or deviated fundus may indicate uterine atony or retained placental fragments, which can cause excessive bleeding and clots.

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A nurse is caring for a client 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following is the nurse's first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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