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) The normal range for hemoglobin (Hgb) in a full-term newborn is approximately 14 to 24 g/dL. A level of 9.5 g/dL is considered low and can indicate anemia, which may require further investigation and treatment.
- B) A platelet count of 225,000/mm³ is within the normal range for a full-term newborn, which typically falls between 150,000 to 450,000/mm³. Therefore, this value would not need to be reported.
- C) A glucose level of 60 mg/dL is within the normal range for a full-term newborn, which is typically 40 to 60 mg/dL shortly after birth. This level indicates that the newborn's glucose is being regulated properly.
- D) A white blood cell (WBC) count of 10,000/mm³ is within the normal range for a full-term newborn, which can range from 9,000 to 30,000/mm³. This suggests the absence of infection or inflammation.
Correct Answer is A
Explanation
A: Minimizing strong odors can help reduce nausea, especially when preparing or cooking food.
B: Eating foods at warm temperatures may be helpful, but it is not as directly related to reducing nausea as minimizing strong odors.
C: Increasing fluids can be helpful, but it is not specifically related to reducing nausea early in the day.
D: Brushing teeth after meals is important for oral hygiene but may not have a significant impact on reducing nausea.
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