A patient is in the immediate postpartum period after having delivered 9 pound. 14-ounce baby (4480 grams). iS 6. The patient is gravida 6, para 5. The nurse notices some new blood stains on the top sheets and discovers the patient lying in a pool of blood. The fundus is located above the umbilicus and is boggy. The bladder is not palpable. What would be the nurse's priority action?
Massage the fundus
Take the patient's blood pressure
Start an IV
Have the patient empty her bladder
The Correct Answer is A
A) Massage the fundus:
The first priority in this situation is to massage the fundus to help control potential postpartum hemorrhage caused by uterine atony. A boggy fundus (soft and not firm) suggests that the uterus is not contracting effectively, which can lead to excessive bleeding. Massaging the fundus stimulates uterine contractions, which can help reduce bleeding by compressing the blood vessels that were supplying the placenta. The nurse should begin with this intervention immediately to address the most likely cause of the bleeding.
B) Take the patient's blood pressure:
While vital signs such as blood pressure are important for assessing shock or ongoing hemorrhage, massaging the fundus takes priority in this scenario to directly address the cause of the bleeding. Taking the blood pressure is not the most immediate intervention for this specific situation because the primary issue here is uterine atony, not hemodynamic instability (although it will need to be assessed shortly thereafter).
C) Start an IV:
Starting an IV may be important if there is significant blood loss, but it is not the first priority in this scenario. The nurse should first focus on stabilizing the uterus by massaging the fundus. IV access will become more critical if the bleeding is not controlled after the fundus is massaged and other interventions are required.
D) Have the patient empty her bladder:
While a full bladder can sometimes displace the uterus and cause it to be less effective at contracting, this is a secondary concern. The first priority is to address the uterine atony by massaging the fundus. Once the fundus is firm and bleeding is under control, the nurse can then consider having the patient empty her bladder to ensure it isn't interfering with the uterus' ability to contract.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Prolactin:
Prolactin is the primary hormone responsible for stimulating milk production in the postpartum period. In breastfeeding mothers, prolactin levels remain elevated, especially during the first few weeks after delivery, to support lactation. This hormone is released in response to suckling and is essential for maintaining a steady milk supply. Elevated prolactin levels help establish and maintain breastfeeding during the early postpartum period, even as other pregnancy-related hormones begin to decline.
B) Estrogen:
Estrogen levels drop sharply after childbirth, as the placenta is no longer present to produce this hormone. The decline in estrogen is one of the factors that helps initiate lactation. While estrogen rises later during the postpartum period as the body returns to its non-pregnant state, it is not elevated during the immediate postpartum period in breastfeeding women.
C) Progesterone:
Similar to estrogen, progesterone levels fall quickly after delivery. Progesterone is involved in maintaining pregnancy, and its levels decrease significantly once the placenta is delivered. A reduction in progesterone is one of the hormonal changes that triggers the onset of lactation. It does not remain elevated in the immediate postpartum period.
D) Human placental lactogen (hPL):
hPL is produced by the placenta during pregnancy to support fetal growth and prepare the breasts for lactation. However, after delivery, hPL levels decline rapidly because the placenta is expelled. It is not elevated in the immediate postpartum period.
E) Relaxin:
Relaxin is a hormone that helps to soften the cervix and relax the ligaments in preparation for childbirth. Its levels are elevated during pregnancy and drop significantly after delivery. It does not remain elevated in the postpartum period, particularly in breastfeeding women.
Correct Answer is A
Explanation
A) "Keep umbilical cord dry and above the level of the diaper."
The umbilical cord stump should be kept clean, dry, and exposed to air as much as possible to prevent infection. The diaper should be folded below the stump to ensure that it remains dry and doesn’t rub against it, which can lead to irritation or infection.
B) "Baby will need to breastfeed every hour."
Newborns typically breastfeed every 2 to 3 hours, not necessarily every hour. The exact frequency may vary based on the baby's hunger cues. Overstating the frequency of feedings may cause undue anxiety for parents, as newborns may not feed this frequently.
C) "Be sure to always wrap baby in 2 blankets when going outside."
Overbundling can lead to overheating. Newborns should be dressed in appropriate layers for the weather, with one layer more than an adult would wear. The use of two blankets may not be necessary unless it is extremely cold. The key is ensuring the baby is comfortably warm, not overheated.
D) "Limit the amount of time baby is skin to skin with parents."
Skin-to-skin contact is beneficial for newborns, especially in the early days after birth. It promotes bonding, stabilizes the baby’s body temperature, supports breastfeeding, and helps with the baby’s physiological stability. There is no need to limit skin-to-skin contact unless medically contraindicated.
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