A nurse is caring for a client who is postpartum. The client is experiencing excessive vaginal bleeding and has a boggy uterus. Which of the following actions should the nurse take first?
Apply oxygen via a non-rebreather mask at & L/min.
Administer methylergonovine 0.2 mg IM
Encourage the client to empty her bladder
Initiate fundal massage.
The Correct Answer is D
Rationale:
A) Incorrect - Applying oxygen is not the priority action in the case of excessive vaginal bleeding and a boggy uterus. Oxygen therapy would be appropriate if there were signs of respiratory distress or decreased oxygen saturation, but it does not directly address the primary concern of uterine atony and bleeding.
B) Incorrect - Administering methylergonovine might be appropriate, but the priority is to address the uterine atony with fundal massage first. Fundal massage helps stimulate uterine contractions and control bleeding, which is crucial in this scenario.
C) Incorrect - Encouraging the client to empty her bladder is important, but it is not the first action to take in the case of excessive bleeding and uterine atony. Immediate intervention to control the bleeding takes precedence.
D) Correct - Initiating fundal massage is the priority action in this situation. A boggy uterus with excessive vaginal bleeding indicates uterine atony, which is a potentially life-threatening condition requiring immediate intervention to prevent further bleeding.
Fundal massage helps the uterus contract and control bleeding. Addressing uterine atony is critical to prevent further hemorrhage and stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Terbutaline is a tocolytic medication used to relax uterine muscles and inhibit contractions, not to treat an ectopic pregnancy.
B) Incorrect- Magnesium sulfate is used to prevent seizures in clients with preeclampsia, not to treat ectopic pregnancies.
C) Correct - Methotrexate is often used to treat unruptured ectopic pregnancies in the early stages by inhibiting the growth of trophoblastic tissue.
D) Incorrect- Calcium gluconate is used to treat magnesium toxicity and other conditions related to calcium imbalance, not to treat ectopic pregnancies.
Correct Answer is A
Explanation
A) Correct - Reporting crackles is important because they can indicate fluid retention in the lungs, which can be a serious adverse effect of terbutaline.
B) Incorrect- Dizziness is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
C) Incorrect- Nausea is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
D) Incorrect- Tremors are a common side effect of terbutaline and might not warrant immediate reporting unless severe.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today