A nurse is caring for a client who is 2 hours postpartum.
The nurse notes that the client soaked a perineal pad in 10 minutes, the client’s skin color is ashen, and she states she feels weak and light-headed.
After applying oxygen via a non-rebreather face mask at 10 L/min, which of the following actions should the nurse take next?
Tilt the client onto her right side with her legs elevated to at least 30 degrees.
Administer oxytocin by continuous IV infusion.
Insert an indwelling urinary catheter.
Massage the client’s fundus to promote contractions.
The Correct Answer is D
Choice A rationale
Tilt the client onto her right side with her legs elevated to at least 30 degrees. This action is not the most immediate step to take. While it can help improve venous return and thus cardiac output, it does not directly address the issue of postpartum hemorrhage.
Choice B rationale
Administer oxytocin by continuous IV infusion. Oxytocin is a medication that can stimulate uterine contractions and help control postpartum bleeding. However, it should be administered after the nurse has assessed the uterus and determined that it is not contracting effectively on its own.
Choice C rationale
Insert an indwelling urinary catheter. While a full bladder can inhibit effective uterine contractions and contribute to bleeding, inserting a catheter is not the first step in managing a postpartum hemorrhage.
Choice D rationale
Massage the client’s fundus to promote contractions. This is the correct answer. Fundal massage stimulates the uterus to contract, which can help control postpartum bleeding. It is a first-line intervention for a boggy uterus and postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C
Explanation
Choice A rationale
Checking the newborn’s capillary blood glucose level is important, especially for a large for gestational age newborn. Large for gestational age newborns are at risk for hypoglycemia (low blood sugar) after birth. Therefore, regular monitoring of the newborn’s blood glucose level is crucial.
Choice B rationale
Placing the newborn under a radiant warmer can help regulate the baby’s body temperature. Newborns, especially those who are large for gestational age, may have difficulty maintaining their body temperature after birth. A radiant warmer can provide the extra warmth the baby needs.
Choice C rationale
Monitoring the newborn’s temperature is important as newborns can lose heat rapidly, they don’t have the ability to control their body temperature as adults do. Temperature regulation in newborns is important to help them stay healthy and comfortable.
Choice D rationale
Monitoring the newborn’s color and frequency of bowel movements is not directly related to the condition described. While it’s an important aspect of newborn care, it’s not a priority in this scenario.
Correct Answer is D
Explanation
Choice A rationale
While seeing a counselor could be beneficial for some women experiencing doubts and second thoughts about their pregnancy, suggesting this as an initial response may make the client feel that her feelings are abnormal or require professional help.
Choice B rationale
Asking if the client has spoken to her mother about these feelings assumes that the client has a good relationship with her mother or that her mother is available for support, which may not be the case.
Choice C rationale
Telling the client not to worry and that she will be fine once the baby is born may minimize her feelings and does not acknowledge her current emotional state.
Choice D rationale
Ambivalent feelings are quite common for women early in pregnancy. This response validates the client’s feelings and reassures her that what she is experiencing is normal.
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