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 C
Explanation
Hand hygiene is one of the most important infection prevention strategies in the NICU, and parents and visitors should be encouraged to wash their hands frequently, especially before touching the newborn. While wearing gloves can provide an additional barrier against infection, it is not a substitute for hand hygiene. Family members should be encouraged to visit and bond with their newborn, but they should be taught proper infection prevention measures to protect the infant's health. Avoiding direct contact with the newborn is not necessary as long as appropriate infection-prevention measures are taken.
Correct Answer is B
Explanation
The information that the nurse should emphasize in the discharge teaching for a pregnant woman who has undergone a cervical cerclage due to an incompetent cervix is that the presence of any contractions, rupture of membranes (ROM), or severe perineal pressure should be reported to her healthcare provider immediately. This is because these symptoms could indicate cervical dilation or premature labor, which can lead to pregnancy loss or other complications.
Reporting any vaginal discharge is important, but it is not the most critical symptom to monitor for after cervical cerclage placement. Vaginal discharge is common after cervical cerclage and can occur for several weeks without posing a significant risk to the pregnancy.
A cesarean birth may or may not be necessary depending on the patient's individual circumstances and the course of the pregnancy. It is not a given that all women with cervical cerclage require a cesarean delivery.
While some activity restrictions may be necessary after cervical cerclage placement, it is not necessary for the patient to arrange for care at home. Many women are able to manage their daily activities with appropriate precautions and guidance from their healthcare provider.
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