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:
Hydration is crucial during pregnancy, especially for those with preeclampsia. Adequate water intake helps maintain blood volume and reduce blood viscosity, which can help manage blood pressure levels. Drinking 48 to 64 ounces of water daily is recommended to support the increased blood volume needed during pregnancy and to help prevent dehydration, which can exacerbate preeclampsia symptoms.
Choice b reason:
While reducing salt intake can be beneficial for managing blood pressure, it is not necessary to completely avoid salting foods during cooking. Instead, moderation is key. Excessive salt can lead to water retention, which can worsen preeclampsia, but some salt is needed for electrolyte balance and proper body function.
Choice c reason:
Protein is an essential nutrient for fetal growth and the repair and maintenance of maternal tissues. A daily intake of 40 to 50 grams of protein is generally recommended during pregnancy. However, for those with preeclampsia, protein needs may be higher due to potential protein loss in the urine. It's important to monitor protein intake and adjust as needed under medical guidance.
Choice d reason:
Limiting the intake of whole grains, raw fruits, and vegetables is not recommended. These foods provide essential nutrients, fiber, and antioxidants that are beneficial for both maternal and fetal health. They should be included as part of a balanced diet unless there are specific dietary restrictions advised by a healthcare provider.
Correct Answer is C
Explanation
Choice a reason:
While there is always a risk of introducing infection with an internal examination, this is not the primary concern with placenta previa. Infections are a risk with any invasive procedure, but the precautions taken during a typical internal examination minimize this risk.
Choice b reason:
Initiating preterm labor is a concern with any manipulation of the cervix or uterus during pregnancy. However, at 37 weeks, the pregnancy is considered early-term, and the risk of preterm labor is not the primary concern in the context of placenta previa.
Choice c reason:
The primary reason for avoiding an internal examination in a client with placenta previa is the risk of profound bleeding. With placenta previa, the placenta covers part or all of the cervix. An internal examination could disturb the placenta and lead to significant hemorrhage, which can be life-threatening for both the mother and the fetus.
Choice d reason:
While there is a risk of rupturing the membranes during an internal examination, this is not the primary concern with placenta previa. The main issue is the potential for causing significant bleeding due to the placenta's location over the cervix.
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