A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

Prepare to administer a prescribed oxytocic preparation.

Assess the bladder for distention.

Massage the client's fundus.

Assess the client's blood pressure.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Administering a prescribed oxytocic preparation is an important step in managing postpartum hemorrhage, as it helps to contract the uterus and reduce bleeding. However, it is not the first action a nurse should take when a client has saturated a perineal pad within 10 minutes postpartum.

Choice B reason:
Assessing the bladder for distention is also important because a full bladder can impede the contraction of the uterus and lead to increased bleeding. However, this is not the immediate action to take in the event of excessive postpartum bleeding.

Choice C reason:
Massaging the client's fundus is the first action the nurse should take. A boggy uterus, which is soft and not well contracted, can lead to excessive bleeding. Fundal massage stimulates the uterus to contract and can quickly reduce blood loss.

Choice D reason:
Assessing the client's blood pressure is vital to determine the client's hemodynamic status, but it is not the first action to take. The priority is to address the cause of the bleeding and stabilize the client.

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Correct Answer is C

Explanation

Choice A reason:

Precipitous labor is characterized by a labor that progresses rapidly and ends within three hours of its onset. It is not typically associated with painless, bright red vaginal bleeding. This condition is more likely to present with intense, frequent contractions and a rapid change in cervical dilation. Therefore, precipitous labor is not the correct answer in this scenario.

Choice B reason:

Abruptio placentae, also known as placental abruption, is a condition where the placenta detaches from the uterus before delivery. It can cause significant maternal and fetal complications. The classic presentation includes painful bleeding, uterine tenderness, and contractions. Given that the scenario describes painless bleeding, abruptio placentae is less likely to be the correct diagnosis.

Choice C reason:

Placenta previa is a condition where the placenta covers the cervix partially or completely. The hallmark sign of placenta previa is painless, bright red vaginal bleeding, which aligns with the scenario provided. This bleeding can occur spontaneously or be triggered by intercourse or a medical exam. Placenta previa is a serious condition that can lead to maternal and fetal hemorrhage and warrants immediate medical attention. Based on the information provided, placenta previa is the most likely diagnosis for the client described.

Choice D reason:

Threatened abortion refers to vaginal bleeding that occurs in the first 20 weeks of pregnancy, which may indicate a potential miscarriage. Since the client is at 36 weeks gestation, threatened abortion is not a relevant diagnosis for late-term bleeding. Additionally, threatened abortion is often accompanied by abdominal cramping, which is not mentioned in the scenario.

A. 2 cm above the umbilicus B. At the level of the umbilicus C. One fingerbreadth above the symphysis pubis D. To the right of the umbilicus

Correct Answer is B

Explanation

The correct answer is choice B. At the level of the umbilicus.

Choice A rationale:

The fundus is typically not found 2 cm above the umbilicus 12 hours postpartum. This position is more common immediately after delivery or in cases of uterine atony or retained placental fragments.

Choice B rationale:

At 12 hours postpartum, the uterine fundus is expected to be at the level of the umbilicus. This indicates normal involution of the uterus, where it contracts and shrinks back to its pre-pregnancy size.

Choice C rationale:

One fingerbreadth above the symphysis pubis is not a typical position for the fundus 12 hours after delivery. This position is more likely several days postpartum as the uterus continues to involute.

Choice D rationale:

The fundus being to the right of the umbilicus may indicate a full bladder, which can push the uterus to one side. This is not a normal finding 12 hours postpartum and would require intervention to empty the bladder.

: https://bchsfoutreach.ucsf.edu/sites/bchsfoutreach.ucsf.edu/files/handouts/Washington%20Hospital%20Postpartum%204-2018.pdf : https://nursekey.com/fundal-palpation-postpartum/

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A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

Correct Answer is C

Explanation

A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

Correct Answer is B

Explanation

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