A nurse is caring for a client who is 1 hr postpartum.
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.
Select the 6 actions the nurse should take.
Firmly massage the uterine fundus.
Provide emotional support.
Administer oxygen.
Weigh the perineal pads.
Insert indwelling urinary catheter.
Administer methylergonovine.
Administer terbutaline.
Correct Answer : A,B,C,D,E,F
A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss.
D: Correct. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
E: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively.
F: Correct. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
G: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
A. Natal Infant Pain Scale (NIPS): The NIPS is a behavioral assessment tool designed for both preterm and full-term neonates. It evaluates six behavioral indicators in response to painful procedures. These indicators include changes in facial expression (such as grimacing, brow bulge, and eye squeeze), body movements (such as fisting, tremulousness, and limb withdrawal), and other signs of distressChoice B reason:
FACES pain rating scale The FACES pain rating scale should not be used because it is a visual scale that uses facial expressions to assess pain in children who can communicate using pictures of faces displaying different emotions. It is generally used for older children and not appropriate for newborns.
Choice C reason
Premature Infant Pain Profile (PIPP): The PIPP is another pain assessment tool specifically developed for preterm infants. It considers physiological and behavioral parameters, including facial expressions, heart rate, oxygen saturation, and gestational age. While useful for preterm infants, it may not be the best choice for full-term newborns.Since the newborn in this scenario was delivered at 38 weeks of gestation, the PIPP would be an appropriate pain assessment tool to use. It considers specific physiological and behavioural indicators of pain in newborns and helps healthcare providers evaluate and manage pain in this vulnerable population.
Choice D reason:
Visual analog scale (VAS) should not be used because the visual analog scale is a pain assessment tool typically used for older children, adolescents, and adults who can understand and provide a subjective rating of their pain intensity along a linear scale. It involves marking a point on the line corresponding to the level of pain experienced. Since newborns cannot communicate in this way, the VAS is not suitable for their pain assessment.
Correct Answer is B
Explanation
- Urinary output is an important indicator of fluid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess fluid that was retained during pregnancy and the diuretic effect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
- However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
- Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.
Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.
Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.
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