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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.
Choice B rationale:
Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.
Choice C rationale:
Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.
Choice D rationale:
Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.
Correct Answer is C
Explanation
Choice A rationale:
Tamoxifen is not used to treat Non-Hodgkin's lymphoma. Tamoxifen is a selective estrogen
receptor modulator (SERM) and is primarily used in breast cancer treatment. It functions by
binding to estrogen receptors, blocking estrogen's effects, and inhibiting the growth of
hormone-sensitive breast cancer cells.
Choice B rationale:
Tamoxifen is not used to treat endometriosis. Endometriosis is a condition in which tissue
similar to the lining of the uterus grows outside the uterus, and it is typically managed with
hormonal therapies, pain medications, or surgical interventions, but not tamoxifen.
Choice C rationale:
This is the correct choice. Tamoxifen is widely used in the treatment of breast cancer,
especially in cases of estrogen receptor-positive breast cancer. It helps prevent cancer
recurrence and is often prescribed for both early-stage and advanced breast cancer patients.
Choice D rationale:
Tamoxifen is not used to treat polycystic ovary syndrome (PCOS). PCOS is a hormonal
disorder characterized by enlarged ovaries with small cysts, and it is typically managed with
lifestyle changes, hormonal contraceptives, and medications to regulate menstrual cycles and
manage symptoms like hirsutism and acne.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today