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
Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Diminished deep tendon reflexes are not typically associated with NAS3.
Choice B rationale
The Moro reflex, also known as the startle reflex, is one of the many reflexes that babies are born with. An absent Moro reflex is not typically associated with NAS3.
Choice C rationale
Excessive crying is a common symptom of NAS. Babies with NAS are often irritable and hard to comfort.
Choice D rationale
Decreased muscle tone is not typically associated with NAS. In fact, babies with NAS often have increased muscle tone, which can result in tight muscle tone and difficulty relaxing muscles.
Correct Answer is D
Explanation
Choice A rationale
Applying triple antibiotic ointment on the baby’s umbilical cord is not typically recommended. The American Academy of Pediatrics advises against applying any antiseptic or antibiotic ointment to the umbilical cord stump in most cases.
Choice B rationale
Giving a newborn an immersion bath daily is not recommended. Newborns do not need daily baths, and excessive bathing can dry out their skin.
Choice C rationale
Swaddling a baby with their legs in an extended position is not recommended. This position can increase the risk of developmental dysplasia of the hip.
Choice D rationale
Offering a pacifier during naps or at bedtime can be part of a safe sleep routine for a newborn, once breastfeeding is well established.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
