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 B
Explanation
A. Incorrect. While using a disposable razor is a precaution for individuals taking anticoagulants to reduce the risk of bleeding, it is not specific to warfarin.
B. Correct. Taking oral contraceptives along with warfarin can increase the risk of bleeding.
Therefore, the client should be advised not to take oral contraceptives while on warfarin.
C. Incorrect. Aspirin is not typically recommended for pain relief in individuals taking warfarin due to the increased risk of bleeding.
D. Incorrect. The duration of warfarin therapy is individualized based on the specific condition being treated. It is not a fixed 2-week period.
Correct Answer is D
Explanation
A. Nausea is a common side effect of terbutaline, but it is not typically a cause for concern. It may be managed with measures like taking the medication with food.
B. Tremors are a known side effect of terbutaline. While they may be uncomfortable for the client, they are an expected side effect and not necessarily indicative of a problem requiring immediate intervention.
C. Dizziness can occur as a side effect of terbutaline. It is important to monitor the client for this, but it is not typically a severe side effect that requires immediate reporting to the provider.
D. Crackles (also known as rales) in the lungs suggest the possibility of fluid accumulation, which could be a sign of pulmonary edema. This is a serious concern and should be reported to the provider promptly, as it may require a change in treatment or further evaluation.
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