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 C
Explanation
Choice A rationale
Neonatal abstinence syndrome is a condition that results from withdrawal from exposure to narcotics. It is not related to the newborn’s weight.
Choice B rationale
While a yellowish skin tone may indicate jaundice, this is not directly related to the newborn’s weight. Jaundice is caused by an excess of bilirubin, a yellow-orange substance in the blood.
Choice C rationale
Newborns with low birth weight are at risk for hypoglycemia because they have less stored glycogen. They may use up their glucose stores quickly and not have enough intake to maintain their blood glucose levels.
Choice D rationale
Neonatal sepsis is a severe infection in an infant less than 28 days old. It is not directly related to the newborn’s weight but can be associated with maternal infection.
Correct Answer is C
Explanation
Choice A rationale
Drying the infant off and covering the head is important to prevent heat loss, but it is not the first action to be taken. The newborn’s body temperature can drop rapidly because of the evaporation of amniotic fluid, so drying the infant is a priority, but not the first one.
Choice B rationale
Stimulating the infant to cry is important as it helps to clear the lungs of amniotic fluid and promotes the expansion of the lungs for effective oxygenation. However, this is not the first action to be taken. The first action is to clear the respiratory tract.
Choice C rationale
Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly. This is done by suctioning the mouth first and then the nose to prevent aspiration of mucus or amniotic fluid, which can lead to respiratory distress.
Choice D rationale
Cutting the umbilical cord is done after the newborn’s respiratory status is stable. It is not the first action to be taken. The umbilical cord is usually clamped and cut by the healthcare provider after it has stopped pulsating, or after the newborn has started to breathe on their own.
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