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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Placental insufficiency is a significant cause of a newborn being small for gestational age. It occurs when the placenta cannot deliver an adequate supply of nutrients and oxygen to the fetus. This condition can result from several factors, including maternal hypertension, diabetes, and certain infections. Placental insufficiency leads to intrauterine growth restriction (IUGR), which is often diagnosed when a fetus's estimated weight is below the 10th percentile for its gestational age¹². The normal range for fetal growth varies, but a key indicator is the consistent growth along a certain percentile line on growth charts.
Choice B reason:
Fetal hyperinsulinemia is typically associated with mothers who have diabetes. Insulin acts as a growth hormone; thus, excessive insulin can lead to macrosomia, where the newborn is larger than normal for the gestational age, not smaller². Therefore, fetal hyperinsulinemia is not a likely cause of SGA.
Choice C reason:
Preterm delivery can result in a newborn being small for gestational age simply due to the fact that the baby is born before reaching full term and having the opportunity to achieve the expected in-utero growth. However, being born preterm does not necessarily mean the infant is SGA; it means the infant is smaller than full-term babies because they have had less time to grow in utero¹.
Choice D reason:
Perinatal asphyxia refers to a lack of oxygen to the fetus during the time immediately before, during, or after birth. While it can lead to various complications and is a serious condition, it is not a direct cause of a newborn being small for gestational age. Perinatal asphyxia can occur in infants of any gestational age or size².
Correct Answer is B
Explanation
Choice a reason:
Mastitis is an infection of the breast tissue that results in pain, swelling, warmth, and redness. The symptoms of mastitis typically include breast tenderness, redness on the skin, breast pain, and sometimes fever and malaise. While the client's breasts are described as hard and warm, which could be associated with mastitis, the absence of other key symptoms such as fever or flu-like symptoms suggests that mastitis may not be the issue here.
Choice b reason:
Three days postpartum, it is normal for the fundus to be below the umbilicus and for lochia rubra to be present. The hardness and warmth of the breasts could be due to milk coming in, which is also a normal postpartum change. Without additional symptoms of concern, such as fever, severe pain, or signs of infection, it is reasonable to conclude that no additional interventions are required at this time.
Choice c reason:
Removing a nursing bra can provide comfort, especially if it is too tight and contributing to breast engorgement or clogged ducts. However, there is no indication that the client's nursing bra is causing an issue. Nursing bras are designed to support the breasts during breastfeeding and typically do not need to be removed unless they are causing specific problems.
Choice d reason:
Applying a heating pad can help with milk let-down and relieve discomfort from engorgement or clogged ducts. However, since the client is not exhibiting signs of mastitis or severe engorgement, and the warmth of the breasts may be due to normal postpartum changes, the application of a heating pad is not necessarily indicated at this time.
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