A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?
Massage the client's fundus.
Insert an indwelling urinary catheter.
Administer oxygen at 10 L/min
Elevate the client's right hip
The Correct Answer is A
A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.
B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.
C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.
D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.
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Related Questions
Correct Answer is B
Explanation
A. Administering oxygen at 10 L/min via a nonrebreather mask is an important intervention, but changing the client's position is the priority action when late decelerations are observed. Oxygen administration can follow, but optimizing uteroplacental perfusion through changing position is crucial.
B. Changing the client's position is the correct first action.
Repositioning the client, particularly from a supine to a side-lying position, can help alleviate compression on the vena cava and improve blood flow to the uterus, reducing the likelihood of late decelerations.
C. Applying a fetal scalp electrode is not the initial action when late decelerations are noted. Repositioning the client should be attempted first to address potential issues related to uteroplacental perfusion.
D. Increasing the rate of the intravenous (IV) infusion might not directly address the issue of late decelerations. It's important to focus on maternal positioning first to improve blood flow to the uterus.
Correct Answer is C
Explanation
The correct answer is C. Assess the fetal heart rate.
A. Providing clean, dry underpads is important for maintaining cleanliness and comfort, but it is not the priority immediately following an amniotomy.
B. Monitoring the client's temperature is a consideration but is not the priority immediately following an amniotomy. Assessing the fetal well-being takes precedence.
C. Assessing the fetal heart rate is the priority action.
Following an amniotomy, there is a risk of cord prolapse or compression, and assessing the fetal heart rate helps detect any signs of fetal distress or compromise.
D. Assessing the odor of the amniotic fluid may be relevant, but it is not the immediate priority after an amniotomy. Focusing on fetal well-being is crucial.
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