A nurse is caring for a postpartum client who delivered vaginally yesterday and has been experiencing heavy vaginal bleeding since delivery.
Which of the following actions should the nurse take first?
Assess vital signs.
Palpate fundus.
Administer oxytocin as prescribed.
Check perineal pad.
The Correct Answer is B
The correct answer is B. Palpate fundus.
The nurse should first assess the fundus to determine if it is firm and at the expected level of involution.
A boggy or displaced fundus can indicate uterine atony, which is the most common cause of postpartum hemorrhage.
By massaging the fundus, the nurse can stimulate uterine contractions and reduce bleeding.
A. Assess vital signs.
This statement is wrong because assessing vital signs is not the first action the nurse should take.
Vital signs can indicate the severity of blood loss and shock, but they do not address the cause of bleeding.
C. Administer oxytocin as prescribed.
This statement is wrong because administering oxytocin is not the first action the nurse should take.
Oxytocin is a medication that can enhance uterine contractions and reduce bleeding, but it should be given after assessing and massaging the fundus.
D. Check perineal pad.
This statement is wrong because checking perineal pad is not the first action the nurse should take.
Checking perineal pad can help estimate the amount of blood loss, but it does not address the cause of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
The correct answer is choice A, C, D and E. These are all non-pharmacological methods of pain relief that can be used during labor.They work by providing natural pain relief, increasing endorphins, creating competing impulses in the nervous system, or reducing muscle tension and anxiety.
Choice B, biofeedback, is wrong because it is a technique that involves monitoring and controlling physiological responses such as heart rate, blood pressure, muscle tension, and brain waves.It requires special equipment and training and is not commonly used during labor.
Normal ranges for pain during labor vary depending on the individual, the stage of labor, and the method of pain relief.Some factors that can influence pain perception are fear, anxiety, fatigue, previous experiences, expectations, and coping skills.
Correct Answer is ["E"]
Explanation
Increased sleepiness and difficulty waking up are signs of central nervous system (CNS) depression in breastfed infants exposed to codeine through breast milk.Codeine is converted into morphine in the body, which can pass into breast milk and cause adverse effects in the baby.Codeine use by breastfeeding mothers can cause CNS depression in breastfed infants.
Therefore, the nurse should watch for increased sleepiness and difficulty waking up in the baby.
Choice A is wrong because increased alertness and activity are not signs of CNS depression.
They are more likely to be signs of stimulation or agitation.
Choice B is wrong because decreased appetite and weight gain are not specific signs of codeine exposure.
They can be caused by many other factors, such as illness, infection, or poor latch.
Choice C is wrong because increased respiratory rate and depth are not signs of CNS depression.
They are more likely to be signs of respiratory distress or infection.
Choice D is wrong because decreased heart rate and blood pressure are not signs of CNS depression.
They are more likely to be signs of shock or hypovolemia.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Respiratory rate: 30 to 60 breaths per minute
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