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
The correct answer and explanation is:
d) Massage the fundus and avoid direct pressure on the cesarean incision.
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.
a) Insert an indwelling catheter to empty the bladder and contract the fundus.
This is not the first action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Inserting an indwelling catheter requires a physician's order and may cause discomfort and infection. The client may already have a catheter in place after the surgery.
b) Check fundal consistency and continue to monitor the lochial flow amount.
This is not enough to do for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Checking fundal consistency and monitoring lochial flow are important, but they do not address the cause of bleeding or prevent further blood loss.
c) Return the client to bed and maintain bedrest until the lochial flow slows.
This is not appropriate for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Returning the client to bed and maintaining bedrest may delay ambulation and increase the risk of thromboembolism. It also does not stop the bleeding or treat the underlying cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
An altered level of consciousness is not a typical finding in Alzheimer's disease. This condition is characterized by cognitive decline and memory impairment, but consciousness itself is not directly affected.
Choice B rationale:
Rapid mood swings can occur in individuals with Alzheimer's disease due to the changes in brain structure and function. These mood swings are a common behavioral symptom. However, the more distinctive hallmark of Alzheimer's disease is the cognitive decline rather than mood swings.
Choice C rationale:
Excessive motor activity is not a prominent feature of Alzheimer's disease. Instead, individuals with Alzheimer's disease often experience a decline in motor skills and coordination as the disease progresses.
Choice D rationale:
Failure to recognize familiar objects is a common symptom of Alzheimer's disease. This is referred to as agnosia, where individuals may struggle to recognize familiar people, objects, or places. It results from the progressive damage to brain regions responsible for memory and sensory processing.
Correct Answer is ["A","D","E"]
Explanation
Since the pregnant woman is vegetarian and does not eat meat, the practical nurse (PN) should provide alternative sources of iron-rich foods. Lentils and black beans are excellent vegetarian sources of iron and can be added to soups to increase iron intake (option a).
Oatmeal is a good choice for breakfast as it is often fortified with iron (option d). This can help supplement
iron intake in the diet.
Green leafy vegetables, such as spinach, kale, and broccoli, are also rich in iron and should be increased in the client's diet (option e).
Option b, which suggests eating red meat just until the anemia is resolved, is not appropriate for a vegetarian client.
Option c, taking two prenatal vitamins with iron daily, is not necessary unless specifically advised by the healthcare provider. It is important to follow the prescribed dosage of medication and supplements as directed by the healthcare provider.
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