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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":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

  • Color: Consistent with genetic background

    • Interpretation: B) Sign of potential improvement
    • Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.

  • Axillary Temperature: 36.3°C (97.4°F)

    • Interpretation: B) Sign of potential improvement
    • Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.

  • Reflex Irritability: Cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.

  • Muscle Tone: Flaccid

    • Interpretation: C) Sign of potential worsening condition
    • Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.

  • Respiration Effort: Good cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.

  • Heart Rate: 140/min

    • Interpretation: B) Sign of potential improvement
    • Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Correct Answer is C

Explanation

Choice A rationale:
Human papillomavirus vaccine is not typically administered during pregnancy.
Choice B rationale:
Rubella vaccine is a live vaccine and is generally contraindicated during pregnancy.
Choice C rationale:
Tetanus vaccine is safe and recommended during pregnancy.
Choice D rationale:
Varicella is a live vaccine and is generally contraindicated during pregnancy.

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