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 C
Explanation
Choice A reason:
A blood glucose level of 96 mg/dL is within the normal range for a fasting blood sugar level in pregnancy, which is typically between 70 to 95 mg/dL. It is crucial to monitor blood glucose levels during pregnancy due to the risk of gestational diabetes, which can have adverse effects on both the mother and the fetus.
Choice B reason:
The production of estrogen is indeed enhanced during pregnancy. Estrogen plays a vital role in maintaining the pregnancy, promoting fetal development, and preparing the body for childbirth. Elevated levels of estrogen are expected and contribute to many of the physiological changes experienced during pregnancy.
Choice C reason:
A heart rate of 120 bpm (beats per minute) can be considered slightly elevated during pregnancy. The normal resting heart rate for a pregnant woman is usually between 60 to 100 bpm. However, during pregnancy, the heart rate can increase to accommodate the increased blood volume and the needs of the growing fetus. Given the information provided, the most likely scenario that the nurse should address is the heart rate of 120 bpm, as it is slightly above the normal range and may need monitoring or intervention.
Choice D reason:
Weakened respiratory contractions are not typically expected during pregnancy. Pregnant women may experience shortness of breath due to the growing uterus pushing against the diaphragm, but the respiratory contractions themselves should not be weakened. If this occurs, it may warrant further investigation.
Correct Answer is A
Explanation
Choice A reason:
Tipping the nipple to allow air as the baby sucks can lead to the baby ingesting air, which may cause discomfort and increase the risk of colic. Proper bottle feeding technique involves tilting the bottle to fill the nipple with milk, thus preventing the baby from swallowing air.
Choice B reason:
Keeping the baby's head elevated during feeding is recommended to prevent milk from flowing too fast and to reduce the risk of ear infections and choking. It also aids in proper digestion and helps prevent reflux.
Choice C reason:
Allowing the baby to burp several times during each feeding is important to release any air swallowed during feeding. This can help prevent discomfort, gas, and spit-up. Burping can be done by gently patting the baby's back in different positions such as over the shoulder, sitting up, or lying across the lap.
Choice D reason:
Expecting soft, formed yellow stools is appropriate for a newborn, especially if breastfed, as their stools tend to be soft and a mustard yellow color. The frequency and consistency of stools can vary, but they generally reflect the baby's diet and are an indicator of good health.
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