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","D"]
Explanation
Choice A rationale
A nonstress test (NST) is a test during pregnancy that measures the baby’s heart rate and response to movement. It is designed to ensure the baby is doing well and getting enough oxygen. Your provider might order it during the third trimester if you’re experiencing certain complications.
Choice B rationale
During pregnancy, women need nutrient-rich sources of carbohydrate, in the right amounts. Restriction of simple carbohydrates has been shown to reduce postprandial hyperglycemia, fetal glucose exposure, and fetal overgrowth. Therefore, encouraging the patient to limit carbohydrate intake to 40% of their daily calories could be beneficial.
Choice C rationale
Checking a random blood glucose level once daily is not typically recommended during pregnancy. Instead, blood glucose levels are usually checked at specific times, such as fasting (before breakfast), before other meals, and 1 hour after meals. This helps to provide more accurate information about how the body is managing blood glucose levels throughout the day.
Choice D rationale
Metformin is generally considered safe for use during pregnancy. It can also be used to treat women with gestational diabetes mellitus (diabetes that develops during pregnancy)7. Given the patient’s history and risk factors, it would be reasonable to anticipate a prescription for metformin.
Correct Answer is ["A","B","C"]
Explanation
The correct answers are A. Start breastfeeding with the nipple that is less sore, B. Change the infant’s position on the nipples, and C. Apply breast milk to the nipples before each feeding.
Choice A rationale:
Starting breastfeeding with the nipple that is less sore can help reduce discomfort. The baby tends to suck more vigorously at the beginning of a feeding, so starting with the less sore nipple can minimize pain.
Choice B rationale:
Changing the infant’s position on the nipples can help distribute the pressure more evenly and prevent further irritation of sore areas. Different positions can also help ensure a better latch.
Choice C rationale:
Applying breast milk to the nipples before each feeding can soothe and promote healing of sore nipples. Breast milk has natural antibacterial properties and can help keep the nipples moisturized.
Choice D rationale:
Massaging the breasts and nipples prior to feeding is not typically recommended for reducing nipple soreness. It can potentially cause more irritation and discomfort.
Choice E rationale:
Placing breast pads inside the nursing bra can help absorb leakage and keep the nipples dry, but it does not directly reduce soreness during breastfeeding. It is more of a preventive measure to maintain hygiene.
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