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 A
Explanation
Choice A rationale
Ovulation will indeed remain the same after a tubal ligation. The procedure involves blocking or sealing the fallopian tubes, which prevents the egg from reaching the uterus. However, the ovaries continue to release eggs.
Choice B rationale
A tubal ligation procedure does not affect the length of the menstrual period. The menstrual cycle is regulated by hormones, not the patency of the fallopian tubes.
Choice C rationale
Premenstrual tension or premenstrual syndrome (PMS) is not eliminated by tubal ligation. PMS is related to the hormonal changes that occur during the menstrual cycle.
Choice D rationale
Hormone replacements are not needed following a tubal ligation. The ovaries continue to produce hormones as they did before the procedure.
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.
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