A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?
Assist the client to a sitz bath.
Assess the client's uterine tone.
Encourage the client to breastfeed.
Apply an ice pack to the client's perineum.
The Correct Answer is B
Choice A rationale:
Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.
Choice B rationale:
Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.
Choice C rationale:
Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.
Choice D rationale:
Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Fetal hypoxemia is associated with late decelerations in the fetal heart rate (FHR) tracing. It occurs when the fetus experiences a decreased supply of oxygen, typically due to placental insufficiency or maternal hypotension.
Choice B rationale:
Cord compression can lead to variable decelerations in the FHR tracing. It occurs when the umbilical cord is compressed, restricting blood flow to the fetus temporarily.
Choice C rationale:
Uteroplacental insufficiency causes late decelerations in the FHR tracing. It refers to an inadequate blood flow between the uterus and placenta, resulting in reduced oxygen supply to the fetus.
Choice D rationale:
Head compression is the correct answer for early decelerations in the FHR tracing. It happens during contractions when the fetal head is compressed by the maternal pelvis, leading to a temporary vagal response that slows the heart rate.
Correct Answer is A
Explanation
Choice A rationale:
Terbutaline is a medication commonly used to stop preterm labor by relaxing the uterine muscles. However, it is contraindicated in clients with heart disease or certain cardiac conditions, as it can cause cardiovascular side effects such as increased heart rate, palpitations, and potential arrhythmias.
Choice B rationale:
Cervical dilation of 2 cm is a typical sign of preterm labor, and the prescription for terbutaline is appropriate to prevent further cervical dilation and delay delivery.
Choice C rationale:
A gestational age of 34 weeks indicates preterm labor, which is precisely the scenario where terbutaline would be administered to halt labor progression and extend the pregnancy.
Choice D rationale:
Allergy to penicillin is unrelated to the administration of terbutaline, as they are different medications with distinct mechanisms of action and side effects.
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