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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Decreasing expiratory flow time is not the appropriate intervention in this case. The client's pH and PaCO2 levels suggest respiratory acidosis, which indicates inadequate ventilation. Increasing expiratory flow time might exacerbate the acidosis by reducing ventilation.

Choice C rationale:

Increasing the rate of ventilation (respiratory rate) is a potential intervention to improve the client's acid-base balance. However, it should be done cautiously and under medical supervision to avoid respiratory alkalosis. It is not the first-line intervention in this scenario.

Choice D rationale:

Increasing the ventilator tidal volume may help improve ventilation, but it should also be done under medical guidance to prevent barotrauma. It is not the initial intervention to address the client's respiratory acidosis.

A. Decreasing gastrointestinal (GI) cramping and nausea. B. Chest pain and dysrhythmia. C. Vasodilation of the extremities. D. Hypotension and tachycardia.

Correct Answer is B

Explanation

The correct answer is choiceb. Chest pain and dysrhythmia.

Choice A rationale:

Decreasing gastrointestinal (GI) cramping and nausea are not typical adverse effects of vasopressin.In fact, vasopressin can cause abdominal cramps and nausea as side effects.

Choice B rationale:

Chest pain and dysrhythmia are significant adverse effects of vasopressin.Vasopressin can cause vasoconstriction, leading to myocardial ischemia and arrhythmias.

Choice C rationale:

Vasodilation of the extremities is not an adverse effect of vasopressin.Instead, vasopressin typically causes vasoconstriction, which can lead to peripheral ischemia.

Choice D rationale:

Hypotension and tachycardia are not common adverse effects of vasopressin.Vasopressin is more likely to cause hypertension due to its vasoconstrictive properties.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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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?