A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?
Administer oxytocin.
Observe for pooling of blood under the buttocks.
Check the client's blood pressure.
Massage the client's fundus.
The Correct Answer is D
Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.
Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.
Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.
Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Jaundice in an infant who is 4-hr old. This is because jaundice is a yellow discoloration of the skin and eyes caused by high levels of bilirubin in the blood. Jaundice usually appears between the second and fourth day after birth and lasts for one to two weeks. Jaundice that appears within the first 24 hours of life is considered early-onset jaundice and may indicate a serious problem, such as an infection, a blood type mismatch, or a liver disorder. The nurse should notify the charge nurse of this finding and request a blood test to check the bilirubin level.
Choice A is wrong because a hematocrit of 60% in an infant who is 8-hr old is not abnormal. Hematocrit is the percentage of red blood cells in the blood. Newborns normally have higher hematocrit levels than older children and adults because they have more red blood cells at birth.
Choice C is wrong because a blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old is not abnormal.
Blood glucose is the amount of sugar in the blood. Newborns normally have lower blood glucose levels than older children and adults because they have less glycogen (stored sugar) at birth.
Choice D is wrong because acrocyanosis in an infant who is 2-hr old is not abnormal. Acrocyanosis is a bluish discoloration of the hands and feet caused by poor circulation. Newborns normally have acrocyanosis for the first few days of life because they are adjusting to the temperature outside the womb.
Correct Answer is {"dropdown-group-1":"B"}
Explanation
The Apgar score is a scoring system used by doctors and nurses to assess newborns one minute and five minutes after they are born. The score is based on five criteria: activity, pulse, grimace, appearance, and respiration, with each criterion receiving a score of 0 to 2 points.
If we apply this scoring system to the information provided, the newborn's 1- minute Apgar score would be:
Activity: 1 point (limbs flexed)
Pulse: 1 point (heart rate less than 100 beats per minute) Grimace: 1 point (facial movement/grimace with stimulation) Appearance: 1 point (body pink but extremities blue) Respiration: 1 point (irregular, weak crying)
The total score is 5 points, which is considered moderately abnormal.
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