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 C
Explanation
Choice A rationale:
Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.
Choice B rationale:
Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.
Choice D rationale:
Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. Again, the emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.
Correct Answer is B
Explanation
b) Observe how UAP obtains temperatures - Correct Answer
This is the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Observing how the UAP obtains temperatures will help the PN identify any errors or problems with the technique, equipment, or documentation. The PN can then provide feedback and guidance to the UAP to ensure accurate and reliable temperature measurements.
a) Demonstrate how to use the equipment.
This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Demonstrating how to use the equipment may be helpful, but it should be done after observing how the UAP obtains temperatures and determining the cause of the discrepancy.
c) Show UAP how to chart temperatures.
This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Showing UAP how to chart temperatures may be necessary, but it should be done after observing how the UAP obtains temperatures and verifying the accuracy of the data.
d) Return the thermometer for recalibration.
This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Returning the thermometer for recalibration may be required, but it should be done after observing how the UAP obtains temperatures and ruling out any human or environmental factors that may affect the readings.
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