On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:
massage the woman's fundus.
Begin an intravenous (IV) infusion of Ringer's lactate solution.
Call the woman's primary health care provider.
Assess the woman's vital signs.
The Correct Answer is A
The nurse's first action should be to massage the woman's fundus. A completely saturated perineal pad within 15 minutes after giving birth indicates excessive bleeding, which is also known as postpartum hemorrhage (PPH). Massaging the uterus (fundus) can help it to contract, reduce bleeding, and prevent further blood loss. Once the fundus has been massaged, the nurse should assess the woman's vital signs and continue to monitor her for signs of continued bleeding. If bleeding persists despite massage, the nurse should begin an intravenous (IV) infusion of Ringer's lactate solution and call the woman's primary healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Based on the provided information, the probable diagnosis for the spontaneous abortion in this woman would be a threatened abortion, since the cervix is closed and there is no evidence of expulsion of fetal or placental tissue. A threatened abortion is defined as vaginal bleeding occurring before the 20th week of gestation, with a closed cervical os, and no expulsion of fetal or placental tissue.
The other types of spontaneous abortion are defined as follows:
B. Inevitable abortion: vaginal bleeding and cramping with an open cervical os, with or without expulsion of fetal or placental tissue
C. Missed abortion: fetal demise without expulsion of fetal tissue, and may be associated with a closed cervical os and absence of uterine contractions
D. Incomplete abortion: partial expulsion of fetal or placental tissue, with or without vaginal bleeding, and may be associated with an open cervical os and uterine contractions
Correct Answer is C
Explanation
Infants of diabetic mothers (IDM) are at risk of hypoglycemia because they have been exposed to high levels of glucose in utero. The fetus responds to this high glucose level by producing high levels of insulin to regulate the glucose level. After delivery, the glucose supply from the mother is cut off and the infant's insulin levels remain high, leading to hypoglycemia.
Additionally, the infant's ability to produce glucose is immature and may not be sufficient to maintain normal blood glucose levels, especially if the infant is premature or small for gestational age. Therefore, IDM requires close monitoring of their blood glucose levels to prevent and treat hypoglycemia.
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