A nurse is caring for a client who has postpartum hemorrhage due to uterine atony.
Which of the following actions should the nurse take first?
Massage the fundus
Administer oxytocin
Insert an indwelling urinary catheter
Start an IV infusion of lactated Ringer’s solution
The Correct Answer is A
Massaging the fundus stimulates uterine contractions and helps to stop the bleeding.
This is the first action the nurse should take to manage uterine atony.
Choice B is wrong because administering oxytocin is a pharmacological intervention that can be used after massaging the fundus if bleeding persists.
Oxytocin is a hormone that also stimulates uterine contractions and reduces blood loss.
Choice C is wrong because inserting an indwelling urinary catheter is not a priority action for postpartum hemorrhage.
A full bladder can interfere with uterine contractions and cause displacement of the uterus, but it is not the main cause of uterine atony.
Choice D is wrong because starting an IV infusion of lactated Ringer’s solution is a supportive measure that can be used to replace fluid loss and maintain blood pressure in postpartum hemorrhage.
However, it does not address the underlying cause of bleeding and should not be done before massaging the fundus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Acrocyanosis is the term for the bluish discoloration of the hands and feet that is normal in newborns.It is caused by poor peripheral circulation and ineffective temperature regulation.It usually disappears within 24 to 48 hours after birth.
Choice B is wrong because cyanosis is the bluish discoloration of the skin and mucous membranes that indicates inadequate oxygenation.
It is not normal in newborns and requires immediate intervention.
Choice C is wrong because pallor is the paleness of the skin that indicates poor perfusion or anemia.
It is not normal in newborns and requires further evaluation.
Choice D is wrong because jaundice is the yellowish discoloration of the skin and sclera that indicates elevated bilirubin levels.
It is not normal in newborns within the first 24 hours of life and may indicate hemolytic disease or liver dysfunction.
Correct Answer is C
Explanation
Having a history of fibroids can increase the risk of bleeding, but not postpartum hemorrhage.Fibroids are benign tumors that grow in the uterus and can cause heavy menstrual bleeding, but they do not affect the placenta or the uterus after delivery.
Choice A is wrong because having a large baby can increase the risk of postpartum hemorrhage.
A large baby can overstretch the uterine muscle and cause atony, which is the failure of the uterus to contract properly after delivery.Atony is the most common cause of postpartum hemorrhage.
Choice B is wrong because having a prolonged labor can increase the risk of postpartum hemorrhage.
A prolonged labor can exhaust the uterine muscle and impair its ability to contract after delivery.This can also lead to atony and excessive bleeding.
Choice D is wrong because having a low-lying placenta can increase the risk of postpartum hemorrhage.
A low-lying placenta, also called placenta previa, is when the placenta covers part of the cervix. This condition can increase the risk of postpartum hemorrhage, which is excessive bleeding after childbirth.
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