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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0504"]
Explanation
To calculate the estimated date of birth (EDB), also known as the due date, we use Naegele's Rule, which involves adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). Using this rule, if the LMP was on July 27, the EDB would be:
- Add one year: July 27, 2024
- Subtract three months: April 27, 2024
- Add seven days: May 4, 2024
Therefore, the EDB in MMDD format is 0504.
Reason:
Naegele's Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the date of a woman's last menstrual period (LMP). This calculation assumes a regular menstrual cycle of 28 days and ovulation occurring on the 14th day of the cycle. The EDB is typically set at 40 weeks from the LMP, which is approximately 280 days. While this method provides an estimate, only about 4% of births occur on the exact due date, and most births occur within a range of two weeks before or after the estimated due date.
It's important to note that the EDB is an estimate and can be influenced by factors such as the length of menstrual cycles, the exact day of ovulation, and the date of conception. Ultrasounds and other prenatal tests can provide additional information to refine the due date estimate as the pregnancy progresses.
Correct Answer is C
Explanation
Choice A reason: Blunt force trauma, such as from a car accident or a fall, can indeed cause placental abruption, but it is not the most common risk factor. Trauma can lead to the placenta detaching from the uterine wall, but such events are less frequent compared to other risk factors.
Choice B reason: Cigarette smoking is associated with a variety of pregnancy complications, including placental abruption. However, while smoking does increase the risk, it is not considered the most common risk factor when compared to hypertension.
Choice C reason: Hypertension is the most common risk factor for placental abruption. High blood pressure can damage the blood vessels in the uterus, leading to the placenta detaching prematurely.
Choice D reason: Cocaine use during pregnancy can lead to placental abruption because it causes the blood vessels to constrict, which can reduce blood flow to the placenta and cause detachment. While it is a significant risk factor, it is less common than hypertension in the general population.
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