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
Explanation
Choice A rationale:
The amount of amniotic fluid around the fetus is determined by an ultrasound, not an indirect Coombs’ test.
Choice B rationale:
The indirect Coombs’ test is used to detect Rh-positive antibodies in the mother’s blood.
Choice C rationale:
The risk of hypoglycemia in the newborn is not determined by the indirect Coombs’ test.
Choice D rationale:
Blood flow in the fetus and placenta is studied using Doppler ultrasound, not an indirect Coombs’ test.
Correct Answer is A
Explanation
Choice A rationale:
Hypotension is a common adverse effect of epidural analgesia due to the blockage of sympathetic nerve fibers, which can lead to vasodilation and decreased cardiac output.
Choice B rationale:
Polyuria is not typically associated with epidural analgesia. It could be related to other factors such as fluid administration or underlying medical conditions.
Choice C rationale:
A fetal heart rate of 152/min is within the normal range (110-160 beats/min) and is not an adverse effect of epidural analgesia.
Choice D rationale:
A maternal temperature of 37.4° C (99.4° F) is within the normal range (36.1° C to 37.2° C or 97° F to 99° F) and is not an adverse effect of epidural analgesia.
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