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:
A male condom is a barrier method of contraception that is typically easy to use and accessible. It has the added benefit of providing protection against sexually transmitted infections (STIs). However, its effectiveness can be compromised by improper use or breakage. With typical use, male condoms are about 85% effective.

Choice b reason:
A diaphragm with spermicide is another barrier method that can be used to prevent pregnancy. The diaphragm covers the cervix and the spermicide kills or immobilizes sperm. The effectiveness of a diaphragm with spermicide is generally lower than some other methods, with typical use effectiveness around 88%.

Choice c reason:
An intrauterine device (IUD) is a small device inserted into the uterus by a healthcare provider. IUDs come in two types: hormonal and copper. Both types are highly effective, with over 99% effectiveness. They are long-acting, reversible, and do not require daily attention, which contributes to their reliability.

Choice d reason:
An oral contraceptive, also known as the birth control pill, is a popular method of contraception that requires the user to take a pill at the same time every day. The effectiveness of the pill can be high, but because it relies on user adherence, its typical use effectiveness is around 91%.

A. A pelvic exam is required if you want birth control pills. B. Don't worry, I will be with you during the exam. C. All you need to do is relax. D. What part of the exam makes you most nervous?

Correct Answer is D

Explanation

Choice A reason:
Telling a client that a pelvic exam is required for birth control pills is not accurate. Current medical guidelines indicate that a pelvic exam is not necessary to prescribe oral contraceptive medications, hormonal contraceptives can be safely prescribed based on medical history and blood pressure measurement without the need for a pelvic or breast examination.

Choice B reason:
While offering support is important, simply telling the client not to worry does not address her specific concerns or provide her with information about the process and her options.

Choice C reason:
Advising the client to relax does not acknowledge the validity of her feelings or provide her with any concrete information or support to help alleviate her anxiety.

Choice D reason:
Asking the client what part of the exam makes her most nervous is an open-ended question that invites dialogue. It allows the nurse to provide targeted information and reassurance, addressing the client's specific concerns and promoting a sense of control and participation in her own health care decisions.

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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

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