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 lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min, which of the following actions should the nurse take next?
Insert an indwelling urinary catheter.
Administer oxytocin by continuous IV infusion.
Massage the client's fundus to promote contractions.
Tilt the client onto her right side with her legs elevated to at least 30 degrees.
The Correct Answer is C
Choice A reason:
Inserting an indwelling urinary catheter can be helpful in measuring urine output and reducing bladder distention, which may impede uterine contractions. However, it is not the immediate next step in managing postpartum hemorrhage.
Choice B reason:
Administering oxytocin by continuous IV infusion is a standard intervention to promote uterine contractions after delivery, which helps to control bleeding. However, before starting an oxytocin infusion, it is important to ensure that there are no retained placental fragments and that the uterus is not already well-contracted.
Choice C reason:
Massaging the client's fundus is the priority action because it can stimulate uterine contractions, which are essential for controlling postpartum bleeding. A firm, contracted uterus helps to compress the blood vessels and prevent excessive bleeding.
Choice D reason:
Tilting the client onto her right side with her legs elevated can help improve venous return and may be part of the management for shock. However, the immediate concern in a postpartum client with excessive bleeding is to manage the bleeding by promoting uterine contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Notifying the provider of the findings is important, but it is not the immediate priority. The provider should be informed after initial measures to stabilize the client's condition have been taken.
Choice B reason:
Positioning the client with one hip elevated, also known as the lateral or left-lateral position, is the priority action. This position can help improve blood flow and potentially increase the maternal blood pressure, which is critically low at 92/54 mm Hg. It also helps to optimize uteroplacental perfusion, which is essential for the well-being of both the mother and the fetus.
Choice C reason:
Having the client void can be helpful in preventing bladder distention, which can interfere with labor progress. However, it is not the priority action when the client's blood pressure is significantly low.
Choice D reason:
Asking the client if she needs pain medication is an important part of comfort care during labor. However, addressing the client's low blood pressure is a more immediate concern to prevent potential complications for both the mother and the fetus.
Correct Answer is C
Explanation
Choice A Reason:
It is not necessary to avoid food and fluids the day of the procedure unless specifically instructed by the healthcare provider. Amniocentesis does not typically require fasting; however, some facilities may have different protocols.
Choice B Reason:
A bowel prep protocol is not required for an amniocentesis. This procedure is unrelated to the gastrointestinal tract, and bowel preparation is more commonly associated with procedures like colonoscopy.
Choice C Reason:
Emptying the bladder immediately prior to the procedure is important. A full bladder can obstruct the view of the uterus during ultrasound, which is used to guide the amniocentesis needle. Additionally, an empty bladder reduces the risk of accidental puncture during the procedure.
Choice D Reason:
Washing the abdomen with soap and water the morning of the procedure is a good hygiene practice but is not specifically required for amniocentesis. The area will be cleaned with antiseptic by the healthcare provider before the procedure.
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