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.
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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
In the case of a bioterrorism attack involving anthrax, the main priority for the nurse is to administer antibiotics within 48 hours of exposure using the Strategic National Stockpile. Anthrax is a serious bacterial infection that can be used as a bioterrorism weapon. Antibiotics, such as ciprofloxacin, doxycycline, and penicillin, can be used to prevent anthrax from developing in people who have been exposed.
There is currently no vaccine available for anthrax exposure. Also, symptom support alone is not enough in cases of anthrax exposure, as anthrax can progress rapidly and lead to serious complications. Placing everyone who was exposed in quarantine may not be necessary in all situations, and should be determined on a case-by-case basis depending on the extent and severity of the exposure.
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