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 C
Explanation
Choice A rationale
The risk for newborn infection is primarily associated with prolonged rupture of membranes or maternal infection during labor, not directly with the administration of general anesthesia during a cesarean birth.
Choice B rationale
While the postpartum period is a time of increased risk for DVT due to hormonal changes and decreased mobility, general anesthesia itself does not significantly increase this risk compared to regional anesthesia. Surgical procedures in general increase DVT risk.
Choice C rationale
General anesthesia can lead to uterine atony, a condition where the uterus fails to contract adequately after delivery. This lack of contraction can result in postpartum hemorrhage, making postpartum bleeding the greatest risk associated with general anesthesia in this scenario.
Choice D rationale
The risk for infection is primarily associated with the surgical incision and the postpartum period in general, not specifically with the type of anesthesia used during the cesarean birth.
Correct Answer is B
Explanation
Choice A rationale
Elevating the mother's legs may help with venous return and circulation, but it does not directly address a soft and boggy uterus, which indicates uterine atony and a risk for hemorrhage. The immediate priority is to promote uterine contraction.
Choice B rationale
A soft and boggy uterus indicates uterine atony, a primary cause of postpartum hemorrhage. Massaging the fundus stimulates the uterine muscles to contract, which helps to compress the blood vessels at the placental site and reduce bleeding. This is the most appropriate initial intervention to address uterine atony.
Choice C rationale
Encouraging the mother to void is important in the postpartum period as a full bladder can displace the uterus and interfere with its ability to contract. However, in the presence of a soft and boggy uterus, the immediate priority is to directly stimulate uterine contraction through fundal massage before addressing bladder emptying.
Choice D rationale
Pushing on the uterus to express clots without first ensuring the uterus is firm is contraindicated. A soft, atonic uterus is more susceptible to inversion if pressure is applied. Fundal massage should be performed first to encourage uterine contraction and firmness before attempting to express any clots.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.