A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to:
Assess the location and firmness of the fundus.
Explain that this is normal for second-time moms.
Administer Pitocin as per standing order.
Change her pad and return in 1 hour and reassess.
The Correct Answer is A
A. Correct. The priority is to assess the fundus for firmness and location. Uterine atony is a common cause of postpartum hemorrhage and requires immediate assessment and intervention.
B. Incorrect. Increased bleeding in a multiparous client should not be dismissed as normal without assessment.
C. Incorrect. Administering Pitocin may be appropriate but should follow an assessment of the fundus first.
D. Incorrect. Waiting an hour without assessing the fundus could delay necessary interventions for postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Supporting the uterus decreases the amount of pain." Incorrect. While proper support may reduce discomfort, the primary reason is structural support.
B. "This is necessary because the ligaments that hold the uterus are stretched." Correct. The uterus is enlarged postpartum, and the ligaments are weakened, making support necessary.
C. "This will decrease the severity of uterine bleeding." Not the primary reason, though proper fundal massage can aid in hemorrhage prevention.
D. "This will help with uterine involution." Incorrect. Uterine involution is driven by hormonal changes and contractions, not just support.
Correct Answer is A
Explanation
A. Pulmonary embolism (PE): PE is a life-threatening condition that occurs when a blood clot travels to the lungs, often originating from a deep vein thrombosis (DVT). Postpartum clients are at increased risk due to hypercoagulability. Symptoms include sudden-onset dyspnea, chest pain, tachypnea, tachycardia, and hypoxia despite clear lung sounds. This warrants immediate intervention.
B. Mitral valve collapse: This is not a common postpartum complication and does not explain the client’s acute symptoms.
C. Upper respiratory infection: URIs present with cough, congestion, fever, and abnormal lung sounds, which this client does not have.
D. Thrombophlebitis: This refers to localized inflammation of a superficial vein, which may cause leg pain and swelling but does not typically result in respiratory distress.
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