A nurse is caring for a client who is 4 hr postpartum. The nurse notes four saturated perineal pads in the past hour. Which of the following actions should the nurse take first?
Administer misoprostol.
Increase maintenance IV fluid.
Perform perineal hygiene.
Perform fundal assessment and massage.
The Correct Answer is D
A. administering misoprostol, may be indicated in postpartum care, but it is not the first priority in this situation. The immediate concern is excessive bleeding, which should be addressed first.
B. increasing maintenance IV fluid, is not the first action to take. While fluid management is important, it is not the priority when the client is experiencing excessive postpartum bleeding.
C. performing perineal hygiene, is important for overall hygiene, but it is not the first action to take when the client is experiencing excessive bleeding. Controlling bleeding takes precedence.
D. performing fundal assessment and massage, is the first priority. This helps assess for uterine atony (failure of the uterus to contract), a common cause of postpartum hemorrhage. Massage can stimulate uterine contractions and help control bleeding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. administering misoprostol, may be indicated in postpartum care, but it is not the first priority in this situation. The immediate concern is excessive bleeding, which should be addressed first.
B. increasing maintenance IV fluid, is not the first action to take. While fluid management is important, it is not the priority when the client is experiencing excessive postpartum bleeding.
C. performing perineal hygiene, is important for overall hygiene, but it is not the first action to take when the client is experiencing excessive bleeding. Controlling bleeding takes precedence.
D. performing fundal assessment and massage, is the first priority. This helps assess for uterine atony (failure of the uterus to contract), a common cause of postpartum hemorrhage. Massage can stimulate uterine contractions and help control bleeding.
Correct Answer is D
Explanation
A: The recommended needle length for administering vaccines to newborns is usually ⅝ inch, but the needle choice can vary depending on the infant's size and age.
B: The preferred site for administering vaccines to infants is the vastus lateralis muscle in the anterolateral thigh, not the dorsal gluteal muscle.
C: The gauge of the needle can vary, and a 20-gauge needle may be appropriate depending on the specific vaccine and infant's size.
D: The standard dose for the hepatitis B vaccine for newborns is 0.5 mL.
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