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 D
Explanation
Choice A rationale:
Administering ephedrine IV is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Ephedrine is typically used to treat hypotension during spinal anesthesia, not amniotic fluid embolism.
Choice B rationale:
Assisting the client to empty their bladder is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. While bladder care is important, it is not the priority in this situation.
Choice C rationale:
Assessing for the presence of clonus is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Clonus is typically assessed in clients with preeclampsia or eclampsia, not amniotic fluid embolism.
Choice D rationale:
Preparing to initiate cardiopulmonary resuscitation is the appropriate action for a client experiencing an amniotic fluid embolism during labor. Amniotic fluid embolism can lead to cardiovascular collapse, therefore, immediate resuscitation measures should be prepared15.
Correct Answer is D
Explanation
Choice A rationale:
Desiring privacy with the newborn is not specific to the taking-in phase.
Choice B rationale:
Taking charge of all mothering tasks is more indicative of the taking-hold phase.
Choice C rationale:
Putting personal needs aside is not specific to the taking-in phase.
Choice D rationale:
Reviewing the birth experience with others is characteristic of the taking-in phase.
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