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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased uterine tone: Methylergonovine is a medication used to prevent or treat postpartum hemorrhage. It works by causing uterine contractions, which helps to control bleeding. An indication that the medication is effective would be an increase in uterine
tone, as this signifies that the uterus is contracting appropriately.
B. Blood pressure 120/74 mm Hg: While a blood pressure of 120/74 mm Hg is within the normal range, it does not specifically indicate the effectiveness of methylergonovine.
Blood pressure is an important parameter to monitor, but it alone does not determine the effectiveness of the medication.
C. Decreased perineal edema: Decreased perineal edema may be a positive sign for the client's overall recovery, but it is not a direct indicator of methylergonovine's
effectiveness. Perineal edema is not a primary concern addressed by this medication.
D. Urinary output 100 mL/hr: Urinary output of 100 mL/hr is an important parameter to monitor for renal function. However, it does not specifically indicate the effectiveness of methylergonovine in preventing or treating postpartum hemorrhage. Urinary output is crucial for assessing kidney function and fluid balance but is not directly related to the action of this medication.
Correct Answer is A
Explanation
A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.
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