A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather 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°.
Administer oxytocin by continuous IV infusion.
Insert an indwelling urinary catheter.
Massage the client's fundus to promote contractions.
The Correct Answer is D
A. Tilting the client onto her right side with her legs elevated does not directly address the underlying cause of postpartum hemorrhage.
B. Oxytocin is a uterotonic medication commonly used to help control and prevent PPH by promoting uterine contractions, which can help to compress blood vessels and reduce bleeding. However, it is not the priority action.
C. Inserting an indwelling urinary catheter may be necessary to monitor urine output and empty the bladder but is not a priority.
D. Massaging the client's fundus to promote contractions is a standard intervention and initial action for managing PPH
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The commonest risk factor for placenta abruption is hypertensive diseases in pregnancy. Hypertension can lead to alterations in the blood vessels supplying the placenta, increasing the risk of detachment.
The other are known risk factors but less common.
Correct Answer is D
Explanation
A Covering the umbilical cord stump with the diaper can create a moist environment, which may increase the risk of bacterial growth and infection.
B. Washing the cord stump with soap and water may disrupt the natural drying process and increase the risk of infection
C. Applying petroleum jelly or any other substance to the umbilical cord stump is not necessary and may increase the risk of infection.
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