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
Choice B rationale:
Giving the wife a straw to help facilitate the client's drinking is not the most appropriate action in this situation. The client's facial paralysis and inability to move his left side could be indicative of a possible stroke or cerebral vascular accident (CVA). Before attempting to give the client fluids, it is essential to assess his swallowing reflex to prevent aspiration and ensure safety. Using a straw may not address the underlying issue.
Choice C rationale:
Assisting the wife and carefully giving the client small sips of water without assessing the swallowing reflex can be risky. If the client has impaired swallowing, this action could lead to aspiration and further complications. Assessing the client's ability to swallow is the priority to ensure safe oral intake.
Choice D rationale:
Obtaining thickening powder before providing any more fluids is premature without first assessing the client's swallowing ability. Thickened liquids may be necessary if the client has dysphagia, but the nurse should assess the client's condition and consult with the healthcare provider before making this decision. Assessing the swallowing reflex is the first step in determining the appropriate course of action.
Correct Answer is C
Explanation
Choice A rationale:
The neurology unit supervisor is not the most appropriate nurse to coordinate the progression of care for a client with a spinal cord injury (SCI). While they may have expertise in neurology, the nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including SCI. They can facilitate communication between various healthcare providers and ensure that the client receives comprehensive care throughout their stay.
Choice B rationale:
An adult nurse practitioner may have specialized knowledge in the care of adults, but they may not have the specific skills and training required to coordinate the care of a client with a spinal cord injury in the ICU. Nurse case managers are better equipped to manage complex cases and ensure the continuity of care for the client.
Choice D rationale:
A risk management nurse focuses on minimizing healthcare-related risks and ensuring the safety of patients and staff. While their role is essential, it is not the primary responsibility to coordinate the progression of care for a client with a spinal cord injury. The nurse case manager is better suited for this role as they specialize in care coordination.
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