On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take?
Insert an indwelling catheter to empty the bladder and contract the fundus.
Check fundal consistency and continue to monitor the lochial flow amount.
Return the client to bed and maintain bedrest until the lochial flow slows.
Massage the fundus and avoid direct pressure on the cesarean incision.
The Correct Answer is D
This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding. Avoiding direct pressure on the incision prevents pain and wound dehiscence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Immune thrombocytopenic purpura (ITP) is a condition characterized by low platelet levels in the blood, which can lead to an increased risk of bleeding and bruising. Patients with ITP are at risk of spontaneous bleeding, and any injury can be potentially serious.
Ensuring the client has minimal clutter in the room is essential to reduce the risk of accidental falls and injuries. Falls and bumps can lead to bruising or bleeding, which can be particularly problematic in individuals with low platelet counts.
Incorrect:
A. Assessing the client for nerve pain or paralysis is important in the overall care of the patient, but it may not directly address the prevention of injury in this situation.
C. Evaluating the client's neurological status after exercising is also essential for assessing their overall health and well-being but may not directly prevent injury.
D. Monitoring the client's blood cell laboratory values, including platelet levels, is crucial for managing ITP, adjusting treatment if needed, and ensuring the client's condition remains stable. However, while important, this action is not directly related to preventing immediate injury in the care facility.
Correct Answer is D
Explanation
Verifying the completion of all new prescriptions is crucial because it ensures that necessary medications or treatments are not delayed or missed for the clients. By reviewing the new prescriptions, the PN can ensure that any necessary medications or treatments are ordered and completed as required. This task takes priority because it directly impacts the immediate care and well-being of the clients.
While the other tasks mentioned are also important, they are not as time-sensitive or critical as verifying the completion of new prescriptions:
A. "Clean up and organize the nurses' work-station": While maintaining a clean and organized work-station is important for efficiency and safety, it can be done after the more critical tasks have been completed.
B. "Write a narrative shift summary for each client": Providing shift summaries is important for effective communication and continuity of care, but it can be done after ensuring the completion of new prescriptions, as it involves documenting and reviewing the events and assessments that occurred during the shift.
C. "Calculate and record intake and output totals": Tracking intake and output is important for assessing fluid balance, but it can also be done after verifying the completion of new prescriptions, as it involves documenting and calculating fluid volumes.
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