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A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.

Which of the following actions should the nurse take?

A.

Evaluate urinary output.

B.

Replace the surgical dressing.

C.

Apply an ice pack to the incision site.

D.

Administer 500 mL lactated Ringer's IV bolus.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Evaluating urinary output is important postoperatively, but it does not address the immediate concern of vaginal bleeding.
Choice B rationale:
Replacing the surgical dressing is necessary if it’s saturated, but it does not address the immediate concern of vaginal bleeding.
Choice C rationale:
Applying an ice pack to the incision site can help reduce swelling and pain, but it does not address the immediate concern of vaginal bleeding.
Choice D rationale:
Administering a 500 mL lactated Ringer’s IV bolus can help increase uterine contractility and decrease bleeding. This is the most appropriate action for the nurse to take in this situation.
 


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Related Questions

Correct Answer is A

Explanation

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

  • Subtract 3 months from June 21, which gives you March 21.
  • Add 7 days to March 21, which gives you March 28.
  • Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

Correct Answer is B

Explanation

Choice A rationale:
Removing the diaphragm 2 to 4 hours after intercourse is incorrect because the diaphragm should be left in place for at least 6 hours after intercourse to prevent pregnancy.
Choice B rationale:
Inserting the diaphragm up to 6 hours before intercourse is correct. This allows time for the spermicide to become effective.
Choice C rationale:
Washing the diaphragm with detergent soap between uses is incorrect. Detergent soap can degrade the material of the diaphragm.
Choice D rationale:
Applying a vaginal lubricant to the diaphragm prior to insertion is incorrect. Lubricants can interfere with the effectiveness of the spermicide.

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