When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm and three fingerbreadths above the umbilicus. What action should the nurse implement first?
Check for a distended bladder.
Review the hemoglobin to determine hemorrhage.
Massage the uterus to decrease atony.
Increase intravenous infusion.
The Correct Answer is A
Choice B reason: Reviewing the hemoglobin to determine hemorrhage is an important action, but not the first one. The nurse should first identify and correct the cause of bleeding, such as bladder distension or uterine atony, before checking for blood loss and anemia.
Choice C reason: Massaging the uterus to decrease atony is not indicated in this case, because the uterus is already firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D reason: Increasing intravenous infusion is not the first action, because it may worsen bleeding by increasing blood pressure and diluting clotting factors. The nurse should first assess and manage bleeding before administering fluids or blood products as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Ask for a consultation with a psychologist. This is not the best intervention, as it does not address the physical aspect of pain management. A psychologist may help the client cope with emotional distress and cognitive-behavioral strategies to reduce pain perception, but it may not be enough to relieve severe pain.
Choice B: Arrange an appointment with a pain specialist. This is the best intervention, as it addresses the physical aspect of pain management. A pain specialist may prescribe appropriate medications, perform interventional procedures, or recommend alternative therapies to relieve severe pain.
Choice C: Contact a hospice nurse for an evaluation. This is not the best intervention, as it does not address the eligibility criteria for hospice care. Hospice care is intended for clients who have a terminal illness with a life expectancy of six months or less, and who have decided to forego curative treatments. Fibromyalgia is not a terminal illness, and hospice care may not be appropriate for this client.
Choice D: Form an interdisciplinary team for evaluation. This is not the best intervention, as it does not address the urgency of pain management. An interdisciplinary team may consist of various healthcare professionals who can provide holistic care for the client, but it may take time to coordinate and implement their services.
Correct Answer is D
Explanation
Choice A: Which medication works best for you? This is not the most important question, as it does not address the current status or risk of the client. The medication history is a part of the assessment, but it does not help identify the content or impact of the hallucinations.
Choice B: When do you hear voices? This is not the most important question, as it does not address the current status or risk of the client. The frequency and timing of the hallucinations are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice C: How do you cope with the voices? This is not the most important question, as it does not address the current status or risk of the client. The coping strategies are a part of the assessment, but they do not help identify the content or impact of the hallucinations.
Choice D: What are the voices saying? This is the most important question, as it addresses the current status and risk of the client. The content and impact of the hallucinations are a part of the assessment, as they can help identify if the client is experiencing command hallucinations, which may instruct them to harm themselves or others.
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