A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes.
Which action by the nurse should be implemented first?
Assess the fundus.
Begin an IV infusion of Ringer's lactate solution.
Assess vital signs.
Notify the health care provider.
The Correct Answer is A
Choice A rationale
A saturated perineal pad within 15 minutes suggests a significant hemorrhage. The most common cause of postpartum hemorrhage is uterine atony, a lack of uterine muscle tone. Assessing the fundus first allows the nurse to determine if the uterus is firm or boggy, a key indicator of atony, and to perform a fundal massage if needed to stimulate contractions and reduce bleeding.
Choice B rationale
While an IV infusion may be necessary to restore blood volume, initiating it is not the first action. The nurse must first determine the cause of the bleeding. The fundus assessment provides critical diagnostic information and an immediate opportunity for intervention (massage) that could resolve the bleeding before initiating a fluid resuscitation.
Choice C rationale
Assessing vital signs is important but should not be the first action. In a situation of heavy bleeding, the priority is to identify and address the source of the hemorrhage. A fundal assessment provides this information immediately. Vital signs will change in response to blood loss, but the fundal assessment provides the most direct and immediate action to stop the bleeding.
Choice D rationale
The health care provider must be notified, but this action is not the first step. The nurse must first gather essential assessment data, such as the condition of the fundus, and initiate immediate interventions like a fundal massage if indicated. Notifying the provider without this information will delay appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Racemic epinephrine nebulizer therapy is a highly effective measure for bronchodilation in a child with croup. This alpha-adrenergic agonist works by stimulating receptors in the smooth muscle of the airway. This stimulation leads to vasoconstriction, reducing the mucosal edema and swelling of the vocal cords and trachea that are characteristic of croup. The rapid reduction in upper airway inflammation and swelling directly alleviates stridor and respiratory distress, improving airflow and oxygenation.
Choice B rationale
Teaching a child to take long, slow breaths is generally a technique used for anxiety or to prevent hyperventilation. However, in a child with croup, the upper airway obstruction makes deep breathing difficult and may increase their distress. The effort to take long, slow breaths against a narrowed airway can further exacerbate the child's respiratory effort and may not provide any significant relief from the underlying swelling.
Choice C rationale
Administering an oral analgesic would be ineffective for aiding bronchodilation in a child with croup. The primary issue in croup is upper airway inflammation and edema, not pain. Analgesics, such as acetaminophen or ibuprofen, primarily work to reduce fever and discomfort. They have no direct pharmacological effect on the smooth muscles of the bronchi or on the mucosal swelling that is causing the respiratory distress.
Choice D rationale
Urging a child to continue to take oral fluids is important for hydration, but it does not directly aid in bronchodilation. In a child with significant respiratory distress from croup, encouraging oral fluids may actually pose a risk for aspiration due to their difficulty breathing and potential fatigue. While hydration is a supportive measure, it does not address the underlying pathology of airway swelling and is not a primary intervention for bronchodilation.
Correct Answer is D
Explanation
Choice A rationale
Painting a picture requires fine motor skills and a level of artistic expression that may be beyond a typical toddler's developmental stage. While some toddlers may enjoy making marks on paper, the structured activity of painting a picture is more appropriate for preschoolers. Toddlers are still developing hand-eye coordination and may become frustrated with a task that requires precision.
Choice B rationale
Playing peek-a-boo is a game typically enjoyed by infants who are learning about object permanence. While a toddler may still find it amusing, it is not the most developmentally appropriate activity for a hospitalized toddler who is developing gross motor skills, independence, and exploring their environment. The game does not support the toddler's need for autonomy and movement.
Choice C rationale
Listening to music can be a soothing and pleasant activity for a toddler, especially in a hospital setting. However, it is a passive activity. The most appropriate play for a toddler is one that engages their newfound gross motor skills, sense of autonomy, and exploration. A passive activity like listening to music does not fully meet the developmental needs of this age group.
Choice D rationale
Playing with a push-pull toy is the most appropriate activity for a toddler. Toddlers are in the developmental stage of mastering walking and running. These toys support the development of gross motor skills, coordination, and balance. The activity also encourages independent exploration and a sense of mastery, which aligns with the toddler's psychosocial stage of autonomy versus shame and doubt.
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