A nurse is caring for a client who is 1 hour postpartum following a vaginal birth.
The client has saturated a perineal pad within 10 minutes.
Which of the following actions should the nurse take first?
Prepare to administer a prescribed oxytocic preparation.
Assess the client's blood pressure.
Assess the bladder for distention.
Massage the client's fundus.
The Correct Answer is D
Choice A rationale
Preparing to administer a prescribed oxytocic preparation is a possible intervention for postpartum hemorrhage, but the immediate first step should be to assess the uterus, the most common source of early postpartum bleeding.
Choice B rationale
Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.
Choice C rationale
Assessing the bladder for distention is important as a full bladder can displace the uterus and interfere with its contraction, potentially contributing to bleeding. However, directly addressing the uterine tone is the immediate first step.
Choice D rationale
Massaging the client's fundus is the priority action because uterine atony, a soft and non-contracted uterus, is the most frequent cause of early postpartum hemorrhage. Stimulating the uterus to contract by massage helps to compress the blood vessels at the placental site and decrease bleeding. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cocaine is a stimulant that typically causes fetal tachycardia (an elevated fetal heart rate) due to its sympathomimetic effects, increasing maternal and subsequently fetal heart rate and blood pressure. It does not usually lead to fetal bradycardia.
Choice B rationale
Prolonged umbilical cord compression can lead to fetal bradycardia because it restricts oxygenated blood flow to the fetus. The baroreceptors in the fetus respond to decreased oxygen by slowing the heart rate in an attempt to conserve oxygen and maintain perfusion to vital organs.
Choice C rationale
Fetal anemia, a decrease in red blood cell count, can lead to fetal tachycardia as the heart attempts to compensate for reduced oxygen-carrying capacity by increasing cardiac output. Bradycardia is not a typical initial response to fetal anemia.
Choice D rationale
Terbutaline is a tocolytic medication used to relax the smooth muscle of the uterus and prevent preterm labor. Its side effects often include maternal and fetal tachycardia due to its beta-adrenergic agonist activity.
Correct Answer is B
Explanation
Choice A rationale
Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.
Choice B rationale
Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.
Choice C rationale
Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.
Choice D rationale
Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.
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