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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Tachypnea (rapid breathing) is not typically an adverse effect of epidural anesthesia.
B. Hypertension (high blood pressure) is not typically an adverse effect of epidural anesthesia.
C. Tachycardia (rapid heart rate) can be an adverse effect of epidural anesthesia, potentially due to a decrease in blood pressure leading to a compensatory increase in heart rate.
D. Fever is not a common adverse effect of epidural anesthesia.

A. Left calf tenderness B. Moderate lochia rubra C. Urine output of 3,000 mL D. Breast engorgement

Correct Answer is A

Explanation

A. Left calf tenderness can be a sign of deep vein thrombosis (DVT), which is a serious postoperative complication and should be reported to the provider.
B. Moderate lochia rubra is an expected finding after a cesarean birth.
C. A urine output of 3,000 mL is within normal range and does not warrant immediate reporting to the provider.
D. Breast engorgement is an expected finding in the postpartum period, especially if the client is not breastfeeding. It does not require immediate reporting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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