A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?

Assess the bladder for distention.

Massage the client's fundus.

Prepare to administer a prescribed oxytocic preparation.

Assess client's blood pressure.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing the bladder for distention is an important action, but not the first one. The nurse should first check the uterine tone and position, as a boggy or displaced uterus can indicate uterine atony, the most common cause of postpartum hemorrhage.

Choice B reason: Massaging the client's fundus is the first action to take. The nurse should apply firm, circular pressure to the fundus to stimulate uterine contractions and reduce bleeding. The nurse should also monitor the amount and character of lochia.

Choice C reason: Preparing to administer a prescribed oxytocic preparation is a necessary action, but not the first one. The nurse should first attempt to control the bleeding by massaging the fundus and assessing the bladder. If the bleeding persists, the nurse should administer medications such as oxytocin, methylergonovine, or carboprost to enhance uterine contractions.

Choice D reason: Assessing the client's blood pressure is an important action, but not the first one. The nurse should first manage the bleeding by massaging the fundus and preparing to administer medications. The nurse should also monitor the client's vital signs, including blood pressure, pulse, and temperature, for signs of shock or infection

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Correct Answer is C

Explanation

A. "I don't want to lose control of my ability to make decisions." This statement reflects a fear of losing autonomy, which is common among individuals with chronic illnesses. While it indicates anxiety and concern about the future, it does not directly suggest suicidal ideation.

B. "I am afraid of experiencing pain near the end." This response shows a fear of suffering and pain, which is also common in terminal illnesses. Although it indicates distress, it does not necessarily imply a risk for suicide.

C. "I know that everything will be better soon." This statement can be a red flag for suicidal ideation, as it may imply that the person believes death is imminent or that they have a plan to end their suffering. It suggests a sense of hopelessness and a potential desire to escape their current situation.

D. "I am relying more and more on my partner for support." This response indicates a need for increased support and dependency on a partner. While it shows a reliance on others, it does not directly suggest suicidal thoughts or intentions.

A. Contact the local health department. B. Establish a triage area. C. Administer oxygen therapy. D. Notify the parents of the students.

Correct Answer is B

Explanation

Choice A reason: This statement is not the first action, as it does not address the immediate needs of the students. Contacting the local health department may be necessary to report a potential outbreak or environmental hazard, but it is not a priority.

Choice B reason: This statement is the first action, as it addresses the immediate needs of the students. Establishing a triage area can help the nurse assess the severity of the symptoms, identify the possible cause, and provide appropriate interventions.

Choice C reason: This statement is not the first action, as it may not be appropriate for all students. Administering oxygen therapy may be necessary for some students who have severe respiratory distress, but it is not a universal intervention.

Choice D reason: This statement is not the first action, as it does not address the immediate needs of the students. Notifying the parents of the students may be necessary to inform them of the situation and obtain consent for treatment, but it is not a priority.

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A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?

Nursing Test Bank

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