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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.
Correct Answer is A
Explanation
Choice A rationale
Decreased extremity edema is a positive sign in a client with deep vein thrombosis (DVT) 48 hours postpartum. DVT is a blood clot that forms in a vein deep in the body, often in the lower leg or thigh. Edema, or swelling, is a common symptom. A decrease in edema may indicate that the condition is improving.
Choice B rationale
Redness in the extremity is not a positive sign in a client with DVT1112. Redness can indicate inflammation or infection, which could suggest a worsening of the condition.
Choice C rationale
Leukocytosis, or an increase in the number of white blood cells, is not a positive sign in a client with DVT1112. It can indicate an infection or inflammation, which could suggest a worsening of the condition.
Choice D rationale
Tachycardia, or a fast heart rate, is not a positive sign in a client with DVT1112. It can indicate a response to decreased oxygen levels in the blood, which could suggest a worsening of the condition.
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