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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is not the best indicator of the recovery phase, as it may reflect the initial reaction of the survivors after the disaster. Survivors may still experience emotional distress, physical injuries, or material losses that require assistance and intervention.
Choice B reason: This statement is not the best indicator of the recovery phase, as it may reflect the ongoing efforts of the outside responders during the disaster. Outside responders may work long hours each day to provide rescue, relief, and support to the affected community.
Choice C reason: This statement is not the best indicator of the recovery phase, as it may reflect the challenges faced by the volunteers during the disaster. Volunteers may experience burnout due to the high demands, stress, and trauma of the disaster situation.
Choice D reason: This statement is the best indicator of the recovery phase, as it reflects the resilience and adaptation of the community after the disaster. The community may restore its functions, services, and resources, and cope with the changes and losses caused by the disaster.
Correct Answer is B
Explanation
Choice A reason: This statement reflects concern about personal finances rather than adaptation to the caregiving role. It indicates stress related to balancing work and caregiving responsibilities.
Choice B reason: Arranging for a neighbor to come over demonstrates proactive planning and the ability to delegate responsibilities, which are important aspects of adapting to a caregiving role.
Choice C reason: Apologizing for untidiness may indicate feeling overwhelmed, which can be a sign of difficulty in adjusting to the new responsibilities of caregiving.
Choice D reason: Trying to rearrange the furniture for walker use shows consideration for the client's needs but also suggests ongoing challenges with adapting the living environment for care.
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