A nurse is caring for a client who delivered by cesarean birth 6 hours ago.

The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

Administer 500 mL lactated Ringer’s IV bolus.

Evaluate urinary output.

Apply an ice pack to the incision site.

Replace the surgical dressing.

Answer and Explanation

The Correct Answer is A

Choice A rationale
If a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage after a cesarean birth, administering a 500 mL lactated Ringer’s IV bolus can help increase the client’s circulating volume and support her hemodynamic stability. This is often the first step in managing postpartum hemorrhage.
Choice B rationale
While evaluating urinary output is an important aspect of postoperative care, it would not directly address the issue of ongoing vaginal bleeding.
Choice C rationale
Applying an ice pack to the incision site can help reduce swelling and provide some pain relief, but it would not address the issue of vaginal bleeding.
Choice D rationale
Replacing the surgical dressing is part of routine postoperative care, but it would not directly address the issue of ongoing vaginal bleeding.

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Correct Answer is B

Explanation

Choice A rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended. It’s important for the baby to empty each breast completely, as the fat content of the milk increases as the breast empties.
Choice B rationale
Assessing the newborn’s latch while breastfeeding is crucial. A poor latch can cause sore nipples. The baby should take as much of the areola into their mouth as possible, with more areola showing at the top lip than the bottom.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended for a breastfeeding newborn. Newborns typically need to feed every 2-3 hours, or 8-12 times in 24 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings can interfere with establishing a good milk supply and should be avoided unless medically necessary.

A. Maintain a low stimulation environment B. Weigh the newborn daily C. Advise the parent to avoid breastfeeding D. Avoid eye contact with the newborn during feeding E. Plan to administer naloxone F. Swaddle the newborn with flexed extremities G. Perform Ballard newborn screening each shift . .

Correct Answer is ["A","B","F"]

Explanation

Choice A rationale
Maintaining a low-stimulation environment is recommended for newborns exhibiting clinical findings of NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice B rationale
Weighing the newborn daily is important in the care of a newborn with NAS56. This can help to monitor the newborn’s growth and development, and any significant changes in weight could indicate a need for further medical intervention.
Choice C rationale
Advising the parent to avoid breastfeeding is not typically recommended for mothers who used opioids prior to pregnancy and were prescribed methadone during pregnancy. In fact, breastfeeding is often encouraged for these mothers, as it can help to reduce the severity of NAS symptoms in the newborn.
Choice D rationale
Avoiding eye contact with the newborn during feeding is not typically recommended as part of the care for a newborn with NAS56. Eye contact can help to promote bonding between the parent and the newborn.
Choice E rationale
The administration of naloxone is not typically recommended for a newborn with NAS56. Naloxone is a medication used to reverse the effects of opioids, but it is not typically used in the treatment of NAS56.
Choice F rationale
Swaddling the newborn with flexed extremities can help to comfort a newborn with NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice G rationale
This option is not typically necessary for the management of neonatal abstinence syndrome (NAS). The Ballard score is used to assess gestational age and physical maturity of a newborn, but it is not a routine part of monitoring for NAS.

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A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is one day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is ["A","B","F"]

Explanation

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A nurse is caring for a client who delivered by cesarean birth 6 hours ago.

The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?