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 B
Explanation
Choice A reason: This is incorrect. Hospice care does not provide life extending interventions, but rather focuses on comfort and quality of life for the client and their family⁴⁵.
Choice B reason: This is correct. Hospice care is for people who are in the final stages of an incurable illness and have a life expectancy of 6 months or less⁴⁶. Hospice care helps ease symptoms and provide emotional and spiritual support⁵.
Choice C reason: This is partially correct. Hospice care does allow families to participate in the client's care, but this is not the main goal of hospice care⁴⁵. Hospice care also involves a team of professionals who provide medical, social, and practical support to the client and their family⁴.
Choice D reason: This is incorrect. Hospice services do not end when the client dies, but continue to provide bereavement support to the family for up to a year after the client's death⁴⁵..
Correct Answer is C
Explanation
Choice A reason: Chronic obstructive pulmonary disease (COPD) can increase the risk of falls due to shortness of breath and general weakness. However, it is not the most significant risk factor compared to the musculoskeletal impact of osteoarthritis.
Choice B reason: Chronic kidney disease may contribute to an overall decline in health and can be associated with anemia or bone mineral disorders, which could indirectly increase fall risk. Nonetheless, it does not directly affect the musculoskeletal system as osteoarthritis does.
Choice C reason: Osteoarthritis is the correct answer because it directly affects the joints, leading to pain, stiffness, and reduced mobility. These symptoms can impair balance and coordination, significantly increasing the risk of falls in clients.
Choice D reason: Wide-angle glaucoma primarily affects vision. While visual impairment is a risk factor for falls, osteoarthritis has a more direct impact on the risk of falling due to its effect on joint function and stability.
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