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 B
Explanation
A) Incorrect- Foul-smelling vaginal discharge might indicate infection but is not the priority over the presence of meconium-stained amniotic fluid.
B) Correct- Fetal heart rate is important to monitor, but the presence of meconium- stained amniotic fluid has higher priority. fetal heart tones 98/min, because this indicates fetal distress and requires immediate intervention.
C) Incorrect - Amniotic fluid with meconium noted could indicate fetal hypoxia or distress, but it is not always a sign of a problem and depends on other factors such as gestational age and fetal activity.
D) Incorrect- Maternal temperature elevation might indicate infection but is not the priority over assessing the condition of the amniotic fluid and the baby.
Correct Answer is C
Explanation
A) Incorrect- Taking the medication with breakfast may not ensure optimal absorption of iron, especially if the breakfast does not include a vitamin C source.
B) Incorrect- Taking the medication with the midday meal is not the best option for enhancing iron absorption.
C) Correct - Taking the medication with a glass of orange juice provides a source of vitamin C, which can improve iron absorption.
D) Incorrect- Taking the medication with milk is not recommended, as calcium in milk can interfere with iron absorption.
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