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 A
Explanation
The correct answer is Choice A.
Choice A rationale: In emergencies where immediate surgery is required to save a life, implied consent is assumed if the patient is unresponsive and no family is available. Ethical and legal guidelines allow proceeding without signed consent to avoid delays that could be life-threatening.
Choice B rationale: A close friend typically does not have legal authority to provide informed consent for medical procedures unless they have been designated as a healthcare proxy. Therefore, this action would not be legally appropriate in this situation.
Choice C rationale: Seeking an emergency court order for surgery could cause delays that are detrimental to the patient's health. In life-threatening situations, implied consent is sufficient, and prompt action is necessary to save the patient's life.
Choice D rationale: Continuing to provide life support without proceeding with surgery may not be sufficient to address the life-threatening condition. Immediate surgical intervention is necessary, and implied consent allows this to be done without waiting for a guardian.
Correct Answer is B
Explanation
Choice A rationale:
Assessment of tobacco use geared toward adolescents is an important topic, but it may not directly address the immediate concerns related to the increase in suicides in the community. While substance abuse can be a risk factor for mental health issues, focusing on stress self-management techniques may be more relevant in this context as it can help adolescents cope with various stressors and emotions that could contribute to suicidal thoughts.
Choice C rationale:
Showing statistics on suicide rates may be informative but may not be the most engaging and effective approach to teaching adolescents about mental health. Statistics alone may not provide them with practical tools and strategies to manage their mental well-being.
Choice D rationale:
Providing handouts for local substance abuse treatment centers is important if substance abuse is a concern, but it may not address the broader issue of mental health and suicide prevention. The primary focus should be on teaching adolescents how to manage stress and emotions in a healthy way, as this can be a preventive measure for various mental health issues, including suicidal thoughts.
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