The nurse is assigned to care for the postpartum client during her shift.
The nurse knows one of the most common risk factors for early (PPH) postpartum hemorrhage is uterine atony. When providing care, the nurse would plan to:.

Have the client void frequently.

Massage the uterus.

Have the client in a side-lying position for comfort.

Keep the patient on strict bed rest for 24 hours to avoid stress on the uterus.

Answer and Explanation

The Correct Answer is B

Massaging the uterus helps it contract and prevent excessive bleeding after delivery. Uterine atony is a condition where the uterus does not contract enough to clamp the blood vessels that supply the placenta, leading to postpartum hemorrhage. Uterine massage is one of the interventions to treat uterine atony and restore uterine tone.

Choice A is wrong because having the client void frequently does not directly affect the uterine contraction. However, a full bladder can interfere with uterine contraction and cause displacement of the uterus, so it is important to monitor the bladder status and empty it as needed.

Choice C is wrong because having the client in a side-lying position for comfort does not help with uterine contraction. However, this position may be beneficial for other reasons, such as reducing edema and pain in the perineal area.

Choice D is wrong because keeping the patient on strict bed rest for 24 hours to avoid stress on the uterus does not help with uterine contraction. In fact, early ambulation after delivery can help prevent thromboembolic complications and promote recovery.

Normal ranges for postpartum blood loss are less than 500 mL for vaginal delivery and less than 1000 mL for cesarean delivery. Postpartum hemorrhage is defined as blood loss greater than or equal to 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after birth.

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Correct Answer is C

Explanation

This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.

Choice A: Obtain a full history is wrong because it is not the most urgent action.

A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.

Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.

Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.

Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.

Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.

A. Obtain a serum sample. B. Dry off the newborn. C. Assess the newborn’s Moro reflex. D. Obtain the newborn’s footprints.

Correct Answer is B

Explanation

The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.

The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress.Drying off the newborn also stimulates breathing and crying, which helps clear the airways.

Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.

Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination.Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.

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The nurse is assigned to care for the postpartum client during her shift. The nurse knows one of the most common risk factors for early (PPH) postpartum hemorrhage is uterine atony. When providing care, the nurse would plan to:.

Nursing Test Bank

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Correct Answer is B

Explanation

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The nurse is assigned to care for the postpartum client during her shift.
The nurse knows one of the most common risk factors for early (PPH) postpartum hemorrhage is uterine atony. When providing care, the nurse would plan to:.