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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Understanding the client's living situation is crucial for planning appropriate care post-discharge. The environment must accommodate the special bed and provide a safe space for recovery.
Choice B reason: While applying moisture barrier ointment is important for skin protection, it is not the first action to take when planning discharge. The immediate environment must first be assessed for suitability.
Choice C reason: Assistance with the cost of supplies is valuable, but it is secondary to ensuring the client's living conditions are conducive to recovery and proper care.
Choice D reason: Nutrition is essential for healing, but the initial focus should be on the client's living arrangements to ensure they support the required care and equipment.
Correct Answer is A
Explanation
Choice A reason: This statement is true and relevant. Advance directives are legal documents that allow the client to express their wishes and preferences regarding their health care in case they become unable to communicate or make decisions. They ease the difficult decisions faced by those involved in the client's care, such as family members, health care providers, and legal representatives.
Choice B reason: This statement is false and misleading. Advance directives do not decrease the potential for receiving palliative care, but rather enable the client to choose whether they want to receive it or not. Palliative care is a type of care that focuses on relieving pain and suffering and improving quality of life for clients with serious or terminal illnesses.
Choice C reason: This statement is partially true, but not the best answer. Advance directives help to uphold the ethical principle of veracity, which means telling the truth and respecting the client's autonomy and dignity. However, advance directives also help to uphold other ethical principles, such as beneficence, nonmaleficence, and justice.
Choice D reason: This statement is false and misleading. Advance directives do not detail the doctor's decisions about the client's end-of-life care, but rather detail the client's own decisions and preferences. The doctor's role is to respect and follow the client's wishes as much as possible, unless they conflict with the law or profession
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