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.
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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Related Questions
Correct Answer is C
Explanation
c. "This is expected because of the way iron is broken down during digestion."
The client's stools are black because of the iron supplements, which can cause a harmless change in the color and consistency of the stools. This is due to the oxidation of iron in the gastrointestinal tract, which produces a black pigment called ferrous sulfide. This is not a sign of bleeding or infection and does not require further evaluation or treatment. The nurse should reassure the client that this is a normal side effect of iron supplements and advise her to continue taking them as prescribed.
The other responses are not appropriate and may cause unnecessary anxiety or inconvenience for the client.
The nurse should not ask the client what else she has been eating, as this implies that her diet may be causing her stools to be black. This may confuse or offend the client, who may think that the nurse is questioning her nutritional choices or blaming her for her condition.
The nurse should not tell the client to go to the emergency room, as this suggests that her stools are black because of a serious problem that needs immediate atention. This may frighten or alarm the client, who may think that she or her baby are in danger.
d. The nurse should not tell the client to come to the office, as this indicates that her stools are black because of an abnormal finding that needs further investigation. This may worry or inconvenience the client, who may think that she has a complication or infection that requires testing or treatment.
Correct Answer is B
Explanation
b. Apply an external fetal monitor.
The nurse should apply an external fetal monitor to assess the fetal heart rate and activity, as well as the presence and intensity of contractions. Placenta previa is a condition where the placenta covers part or all of the cervical opening, which can cause painless, bright red bleeding in the third trimester. Placenta previa can compromise fetal oxygenation and perfusion, and can also trigger preterm labor. Therefore, the nurse should monitor the fetal well- being and readiness for delivery.
The other actions are not appropriate and may cause harm to the client or the fetus.
a. The nurse should not perform a rectal exam, as this can cause trauma or infection to the rectum or the placenta, and increase the risk of bleeding or rupture.
c. The nurse should not complete a vaginal exam, as this can dislodge or damage the placenta, and cause severe
hemorrhage or shock.
d. The nurse should not apply ice to the perineal area, as this can cause vasoconstriction and reduce blood flow to the placenta and the fetus, and worsen their condition.
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