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.
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Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Vacuum-assisted delivery is indeed a risk factor for postpartum hemorrhage. This method of delivery can cause trauma to the birth canal, which can lead to increased bleeding after delivery.
Choice B rationale
A history of human papillomavirus (HPV) is not typically associated with an increased risk of postpartum hemorrhage.
Choice C rationale
The newborn’s weight, whether high or low, is not typically considered a risk factor for postpartum hemorrhage.
Choice D rationale
Labor induction with oxytocin is a risk factor for postpartum hemorrhage. Oxytocin is a drug that can cause the uterus to contract too much, leading to uterine atony (a condition where the uterus doesn’t contract properly after birth), which can result in postpartum hemorrhage.
Correct Answer is C
Explanation
Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.
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