A nurse is caring for a client who has just delivered her baby and is at risk for postpartum hemorrhage (PPH).
Which intervention should be included in this client’s plan of care?
Administering oxytocin after delivery
Encouraging frequent voiding
Assessing vital signs every 4 hours
Encouraging ambulation as soon as possible
The Correct Answer is A
Oxytocin is a medication that helps the uterus contract and prevent excessive bleeding after birth. It is the most effective treatment for postpartum hemorrhage, even if already used for labor induction or augmentation or as part of active management of the third stage of labor.
Choice B) Encouraging frequent voiding is wrong because it does not directly affect the risk of postpartum hemorrhage. However, a full bladder can interfere with uterine contraction and cause bleeding, so voiding should be encouraged as part of routine care.
Choice C) Assessing vital signs every 4 hours is wrong because it is not enough to detect and treat postpartum hemorrhage early. Vital signs should be monitored more frequently in the first hour after delivery, when most cases of postpartum hemorrhage occur.
Choice D) Encouraging ambulation as soon as possible is wrong because it does not prevent postpartum hemorrhage.
Ambulation can help prevent thromboembolic complications and promote recovery, but it has no effect on uterine contraction
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Use one hand to stabilize the lower uterine segment while massaging the fundus with the other hand.
This action prevents the uterus from inverting and reduces the risk of trauma to the cervix and vagina.
The nurse should also monitor the amount and consistency of lochia.
Choice B is wrong because applying firm pressure on the fundus with both hands can cause uterine inversion, which is a life-threatening complication of postpartum hemorrhage.
The nurse should use gentle pressure and avoid overstimulation of the uterus.
Choice C is wrong because massaging the fundus in a circular motion with one hand while supporting the back with the other hand can cause displacement of the uterus and increase bleeding.
The nurse should massage the fundus in a downward motion from the top of the uterus to the umbilicus.
Choice D is wrong because rubbing the fundus vigorously with one hand until it becomes hard and expels clots can cause uterine rupture, which is another serious complication of postpartum hemorrhage.
The nurse should avoid excessive manipulation of the uterus and allow clots to pass naturally.
Correct Answer is ["A","B","C"]
Explanation
The correct answer is choice A, B and C. The nurse should monitor intake and output to assess the client’s fluid status and blood loss.
The nurse should elevate the head of the bed to reduce the risk of hypovolemic shock and improve tissue perfusion.
The nurse should apply oxygen via nasal cannula to increase oxygen delivery to the vital organs and prevent hypoxia.
Choice D is wrong because inserting a nasogastric tube is not indicated for a client who has postpartum hemorrhage.
A nasogastric tube is used to decompress the stomach or administer medications or feedings in some conditions.
Choice E is wrong because administering pain medication as needed is not a priority intervention for a client who has postpartum hemorrhage.
Pain medication can mask the signs of shock and lower the blood pressure further.
The nurse should focus on restoring the blood volume and preventing complications.
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