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?
Evaluate urinary output.
Replace the surgical dressing.
Apply an ice pack to the incision site.
Administer 500 mL lactated Ringer's IV bolus.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.
Correct Answer is B
Explanation
Choice A rationale:
Breast tenderness is a common side effect of oral contraceptives and does not need immediate medical attention.
Choice B rationale:
Persistent headaches can be a sign of a serious side effect such as a stroke or blood clot and should be reported immediately.
Choice C rationale:
Vaginal itching could be a sign of a yeast infection, but it’s not typically associated with oral contraceptives.
Choice D rationale:
Painful intercourse could be due to various reasons, but it’s not a common side effect of oral contraceptives.
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