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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 A

Explanation

Choice A rationale:

Keeping the head of the bed raised 45 degrees is a crucial intervention in septic shock. This position helps improve oxygenation and reduces the risk of aspiration. It promotes better lung function and can help maintain a higher mean arterial pressure, which is important in the management of sepsis.

Choice B rationale:

Maintaining strict intake and output is important for assessing fluid balance, but it is not the most critical intervention when a client is in septic shock. Hemodynamic stability and oxygenation take precedence in this situation.

Choice C rationale:

Monitoring blood glucose levels is an essential aspect of care, especially in critically ill patients. However, it is not the most important intervention in the immediate management of septic shock.

Choice D rationale:

Assessing the warmth of extremities is important for circulatory assessment, but it is not the most crucial intervention in septic shock. Hemodynamic support and maintaining oxygenation are higher priorities.

A. Hypertension. B. Apical heart rate 72 beats/minute. C. Muscle weakness. D. Blood pressure 90/76 mm Hg.

Correct Answer is D

Explanation

The correct answer is: D. Blood pressure 90/76 mm Hg.

Clonidine is an alpha-2 adrenergic agonist used to manage withdrawal symptoms, but it lowers blood pressure as a side effect. If the client's blood pressure is already low (90/76 mm Hg), administering clonidine could lead to hypotension, putting them at risk for dizziness, fainting, or more severe complications.

Here's why the other options are not contraindications:

A. Hypertension: Clonidine is actually used to treat high blood pressure, so it wouldn’t be a contraindication.
B. Apical heart rate 72 beats/minute: This heart rate is within normal limits, so it wouldn’t prevent administration.
C. Muscle weakness: While clonidine can cause fatigue, muscle weakness is not a direct contraindication.

Since the client is experiencing withdrawal symptoms like nervousness and unusual sensations ("bones itching"), monitoring vital signs is critical before giving the medication.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider prescribes a sepsis protocol to be initiated.Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

Correct Answer is D

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?