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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?

A.

Administer 500 mL lactated Ringer’s IV bolus.

B.

Evaluate urinary output.

C.

Apply an ice pack to the incision site.

D.

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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Related Questions

Correct Answer is D

Explanation

Choice A rationale
Holding the finger above the heart prior to puncture does not affect the accuracy of a blood glucose test.
Choice B rationale
Smearing the blood onto the reagent strip can result in inaccurate readings.
Choice C rationale
Puncturing the finger while still damp with antiseptic solution can cause discomfort and potentially contaminate the sample.
Choice D rationale
Selecting the lateral side of the finger for puncture is recommended because it is less painful and has good blood flow.

Correct Answer is B

Explanation

Choice A rationale
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.

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