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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Incorrect- the fundal height corresponds with approximately 16 weeks. At around 16 weeks of gestation, the fundal height is usually located approximately at the midpoint between the symphysis pubis (pubic bone) and the belly button (umbilicus). This measurement corresponds to the anatomical level of the uterus at this stage.
B) Incorrect- the fundal height corresponds with approximately 20 weeks. By 20 weeks of gestation, the fundus has typically reached the level of the umbilicus. The fundal height measurement is around the same level as the belly button.
C) Correct- the fundal height corresponds with approximately 32 weeks. Around 32 weeks of gestation, the fundal height has increased significantly compared to earlier stages of pregnancy. The fundus of the uterus is located above the belly button, and the measurement is typically about 32 centimeters (or roughly 12.6 inches) above the symphysis pubis.
D) Incorrect- the fundal height corresponds with approximately 24 weeks. Around 24 weeks of gestation, the fundal height is usually about 1 to 2 fingerbreadths above the
umbilicus. This represents the ongoing upward growth of the uterus as the pregnancy progresses.
E) Incorrect- the fundal height corresponds with approximately 18 weeks. At around 18 weeks of pregnancy, the fundal height is typically located just above the pubic bone, below the belly button (umbilicus). The fundus of the uterus is still relatively low in the abdomen at this point. The fundal height measurement at 18 weeks is usually around the midpoint between the symphysis pubis (pubic bone) and the belly button.

A. Yogurt B. Avocados C. Peanut butter D. Long grain rice

Correct Answer is A

Explanation

A) Correct - Yogurt is a good source of calcium and is a suitable recommendation for a client with low calcium levels during pregnancy.
B) Incorrect- Avocados contain healthy fats and other nutrients, but they are not a particularly high source of calcium.
C) Incorrect- Peanut butter is a source of protein and healthy fats but does not provide a significant amount of calcium.
D) Incorrect- Long-grain rice is a carbohydrate source but does not contribute much to calcium intake.

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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?

Nursing Test Bank

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