The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
Hemoglobin and hematocrit
Abdominal contour and bowel sounds
Heart rate and blood pressure
Urinary output and IV fluid intake
The Correct Answer is C
A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.
B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.
C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.
D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Place client in a negative pressure room:HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.
B. Implement droplet precautions:HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.
C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.
D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).
E. Use standard precautions:Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.
Correct Answer is C
Explanation
A. Estimated amount of fluid:
Knowing the estimated amount of amniotic fluid can provide some information, but it may not be as crucial as other factors in this situation. The primary concern is often related to the color and odor of the amniotic fluid to assess for potential issues.
B. Color and consistency of fluid:
This is a crucial piece of information. The color and consistency of amniotic fluid can provide important clues about fetal well-being and the presence of meconium, which may indicate fetal distress.
C. Time the membranes ruptured:
Knowing the time when the membranes ruptured is essential for assessing the duration of time since the rupture. This information helps in determining the risk of infection, which is a concern after prolonged rupture of membranes.
D. Any odor noted when membranes ruptured:
This is also a critical piece of information. An unpleasant odor, especially if it is foul-smelling, could be indicative of infection. Infection risk increases with prolonged rupture of membranes.
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