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 D
Explanation
Choice A Reason:
Tocolytic therapy is not indicated for a client with a post-term pregnancy. Tocolytics are medications used to suppress premature labor, and a pregnancy at 42 weeks is considered post-term, not preterm.
Choice B Reason:
Braxton-Hicks contractions are normal occurrences during pregnancy and do not indicate preterm labor. They are often referred to as "false labor" because they do not lead to cervical dilation or effacement. Therefore, tocolytic therapy is not necessary.
Choice C Reason:
Administering tocolytic therapy in the case of fetal death is not appropriate. Tocolytics are used to delay preterm labor to allow for fetal maturation or to prolong pregnancy to administer corticosteroids for fetal lung development, which is not applicable in this scenario.
Choice D Reason:
Tocolytic therapy is appropriate for a client experiencing preterm labor at 26 weeks of gestation. The goal of tocolytic therapy is to delay delivery to allow for the administration of corticosteroids to accelerate fetal lung maturity or to transfer the client to a facility equipped for premature infants.
Correct Answer is A
Explanation
Choice a reason:
Panting can help control the urge to push and is often recommended during the crowning stage to prevent tearing and to allow the perineum to stretch gradually. It can also help manage the pain and provide the baby with a gentle descent.
Choice b reason:
Slow-paced breathing is generally advised during the earlier stages of labor to help manage contractions and maintain relaxation. However, during the crowning stage, slow-paced breathing might not be effective in controlling the strong urge to push.
Choice c reason:
Telling the client to go ahead and push without proper guidance could lead to rapid delivery, which increases the risk of perineal tearing. The nurse should instruct the client on when and how to push effectively, often during a contraction, with controlled effort.
Choice d reason:
Taking a deep, cleansing breath can be calming and help the client focus, but it does not directly address the immediate need to control the pushing during crowning. Controlled breathing techniques specific to the delivery stage are more appropriate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.