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
Restlessness, confusion, and agitation in the evening are common symptoms of sundowning, which is a condition that affects some older adults with dementia. Offering to walk around the hallways with the client can provide a calming effect and reduce the symptoms of sundowning.
Dimming the lights may actually increase confusion and agitation, and leaving the client alone may increase feelings of isolation and fear.
Measuring the client's vital signs may not be necessary unless there are specific medical concerns.

Correct Answer is C
Explanation
A positive indirect Coombs' test indicates that the mother has developed Rh antibodies against the baby's Rh-positive blood. This finding can result in hemolytic disease of the newborn, which is a condition in which the mother's Rh antibodies atack the baby's red blood cells, causing destruction and potential anemia.
The baby may require phototherapy for physiologic jaundice, but the Coombs' test result indicates a different issue.
The presence of an infectious blood-borne disease cannot be determined from this test.
The mother may still need Rho (D) immune globulin injections after delivery of an Rh-positive baby.

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