A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
Elevate the client's legs to a 30° angle.
Insert an indwelling urinary catheter.
Massage the client's fundus.
Initiate an infusion of oxytocin.
The Correct Answer is C
Choice C rationale:
The nurse should first massage the client's fundus to address the excessive vaginal bleeding. Massaging the fundus helps the uterus contract and prevents further bleeding. Excessive postpartum bleeding may indicate uterine atony, which is a leading cause of postpartum hemorrhage. The nurse should apply gentle pressure to the fundus to promote uterine contractions and reduce bleeding.
Choice A rationale:
Elevating the client's legs to a 30° angle (Trendelenburg position) is not the priority action in this situation. Fundal massage takes precedence because it directly addresses the cause of the excessive bleeding. While Trendelenburg position might be used in some situations to increase blood flow to vital organs, it is not the first-line intervention for postpartum bleeding.
Choice B rationale:
Inserting an indwelling urinary catheter is not the priority action for excessive vaginal bleeding. While monitoring urine output is essential, the immediate concern is controlling the bleeding by massaging the fundus.
Choice D rationale:
Initiating an infusion of oxytocin may be indicated if fundal massage alone is insufficient to control bleeding. However, massaging the fundus should be the first action taken to promote uterine contractions. Oxytocin can be administered afterward, if needed, under the direction of a healthcare provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
Choice B rationale:
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
Choice C rationale:
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
Choice D rationale:
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
Correct Answer is A
Explanation
A. Palpating the client's uterine fundus is the priority intervention because excessive postpartum bleeding could indicate uterine atony, where the uterus fails to contract effectively. Assessing the fundus will help determine if it is boggy and if fundal massage is needed to promote uterine contraction and reduce bleeding.
B. Assisting the client to urinate is an important intervention if the bladder is distended, as a full bladder can prevent the uterus from contracting properly. However, palpating the fundus to assess the source of bleeding takes priority over assisting with urination.
C. Preparing to administer oxytocic medication may be necessary if the uterine fundus is boggy and does not respond to massage, but the first step is to assess the fundus and attempt manual intervention before proceeding with medication.
D. Increasing the client's fluid intake can help maintain circulation and prevent dehydration, but it does not address the immediate concern of postpartum hemorrhage. Palpating the fundus is the priority action in this scenario
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