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
Health literacy is defined as the degree to which an individual can obtain, process, and
understand basic health information and services needed to make appropriate health decisions. Basic functional health literacy refers to an individual's ability to read and understand simple health information and instructions.
While all the clients mentioned may be demonstrating health literacy, the ability to read and understand discharge instructions after routine surgery is a basic functional health literacy skill. This client is able to comprehend written health information and follow simple instructions, which is an important aspect of managing their own health care.
The other clients mentioned may be displaying a higher level of health literacy, such as the client who is teaching a class about cancer survival or the client with Type II Diabetes who is using nutritional information to make a grocery list. These individuals may have a greater ability to understand and apply complex health information and navigate the healthcare system.
Correct Answer is C
Explanation
Mom's blood type is A-negative, and baby's blood type is O-positive would place the neonate at risk for physiologic jaundice due to Rh incompatibility. When mom is Rh-negative and baby is Rh-positive, the mother's immune system can create antibodies that attack the baby's red blood cells, leading to the destruction of red blood cells and subsequent release of bilirubin, which can result in jaundice.
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