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 fact that the patient is being treated for depression and is currently taking an antidepressant medication suggests that his loss of interest in sexual intimacy may be related to his medication. Certain antidepressants can cause sexual dysfunction, including decreased libido.
Therefore, obtaining a list of medications currently being taken (A) is the most important information for the PN to obtain. While marital discord (B), frequency of sexual activity (C), and alcohol consumption (D) may be relevant information, they are not as directly related to the patient's current complaint as his medication use.
Correct Answer is C
Explanation
The first action the PN should take is to obtain a point-of-care glucose test. This will provide immediate information about the patient's blood sugar level and help guide further interventions.
Option A, reviewing prior insulin prescriptions, is important but not the first priority.
Option B, checking blood pressure, is also important but not the most immediate concern.
Option D, assessing urine for ketones, can provide useful information about the presence of ketones in the urine, which can indicate diabetic ketoacidosis, but it is not the first action that should be taken.
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