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 B
Explanation
Choice A rationale:
Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.
Choice B rationale:
Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.
Choice C rationale:
Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.
Choice D rationale:
Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.
Correct Answer is B
Explanation
Serum creatinine is the most important laboratory value to review before administering an antibiotic that can cause nephrotoxicity. Nephrotoxicity is an alteration in the function of the kidney due to exposure to certain drugs or toxins.
It can be assessed by measuring the glomerular filtration rate (GFR), which is the rate of clearance of a substance from the blood by the kidneys. Serum creatinine is a waste product of muscle metabolism that is freely filtered by the glomeruli and not reabsorbed or secreted by the tubules.
Therefore, it is a reliable indicator of GFR and renal function. An increase in serum creatinine indicates a decrease in GFR and renal function, which may be caused by nephrotoxic drugs.
The other laboratory values are not directly related to nephrotoxicity or GFR:
- Serum calcium: This may be affected by renal function, but it is not a sensitive or specific marker of nephrotoxicity. It may be altered by other factors such as vitamin D, parathyroid hormone, and bone metabolism.
- Hemoglobin and hematocrit: These may be affected by renal function, but they are not sensitive or specific markers of nephrotoxicity. They may reflect the erythropoietin production by the kidneys, which stimulates red blood cell production in the bone marrow. However, they may also be influenced by other factors such as blood loss, hydration status, and iron deficiency.
- White blood cell count (WBC): This is not related to nephrotoxicity or GFR. It may reflect the presence of infection or inflammation, which may be a cause or a consequence of renal impairment, but it is not a direct measure of renal function.
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