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.

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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Correct Answer is B

Explanation

Choice A rationale:
A WBC count of 9,000/mm is within the normal range (4,500-11,000/mm).
Choice B rationale:
Uterine tenderness is a common symptom of endometritis.
Choice C rationale:
Scant lochia is not typically associated with endometritis.
Choice D rationale:
A temperature of 37.4° C (99.3° F) is within the normal range.

A. "You can bathe and dress your baby if you'd like to.”. B. "I'm sure you will be able to have another baby when you're ready.”. C. "If you don't hold the baby, it will make letting go much harder.”. D. "You should name the baby so she can have an identity.”.

Correct Answer is A

Explanation

Choice A rationale:
Offering the parents the opportunity to bathe and dress their baby can provide a sense of normalcy and closure.
Choice B rationale:
This statement assumes the client wants to have another baby and that they will be able to do so, which may not be the case.
Choice C rationale:
It’s important to allow the parents to grieve in their own way. Some may find holding the baby helpful, while others may not.
Choice D rationale:
While naming the baby can provide an identity, it should be the parents’ decision.

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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?

Nursing Test Bank

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Correct Answer is A

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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?