The practical nurse (PN) is caring for a postpartum client who delivered 5 hours ago and has saturated a perineal pad with a few clots within 15 minutes.
Which action is most important for the PN to implement?
Increase the intravenous infusion rate.
Massage the fundus.
Notify the healthcare provider.
Assess the vital signs.
The Correct Answer is D
The most important action for the PN to implement is to **assess the vital signs**. Saturation of a peripad within 15 minutes to 1 hour after delivery must be promptly reported. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage¹. Early recognition and treatment of PPH are critical to care management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The screening test that should be scheduled for a client who is gravida 4 para 3 at 16-weeks gestation is **Maternal serum alpha-feto protein (MSAFP)**. Second trimester prenatal screening may include several blood tests, called multiple markers. These markers provide information about a woman's risk of having a baby with certain genetic conditions or birth defects. Screening is usually done by taking a sample of the mother's blood between the 15th and 20th weeks of pregnancy (16th to 18th is ideal)².
Correct Answer is A
Explanation
The practical nurse (PN) should ask the client if he is planning to obey the voices, as this will help determine the client's risk for harming himself or others. The PN should also ask about the onset and duration of the symptoms and any factors that may have triggered them, such as drug use or recent stressors. Additionally, the PN should assess the client's perception of the voices, as some individuals may recognize them as a symptom of a mental illness, while others may believe them to be real. It is important for the PN to remain non-judgmental and supportive during the assessment, while prioritizing the client's safety.
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