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
The signs described are consistent with Meconium Aspiration Syndrome (MAS). Meconium aspiration occurs when the fetus has a bowel movement before or during delivery and inhales meconium-stained amniotic fluid into the lungs. This can lead to airway obstruction, chemical pneumonia, and respiratory distress, which may progress to respiratory failure, persistent pulmonary hypertension, and death. The presence of coarse breath sounds, acidosis, and the honeycomb appearance on X-ray are all signs of MAS.
Correct Answer is D
Explanation
It is recommended for all diabetic women of childbearing age. (This statement is not entirely accurate as preconception care is recommended specifically for women with diabetes who are considering pregnancy, not all women of childbearing age.)
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