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 C
Explanation
Choice A rationale
While a child taking candy from a dish may indicate the availability of sugary foods, it does not necessarily reflect the mother's overall efforts to provide a balanced diet. The presence of these foods could be for other family members or guests, and the child's action might not be representative of their regular dietary intake. A balanced diet incorporates multiple food groups, not just the avoidance of sugar.
Choice B rationale
Fried foods are often high in saturated fats and sodium, which can contribute to poor cardiovascular health and obesity. This choice does not demonstrate an understanding of a balanced diet, which emphasizes lean proteins, whole grains, fruits, and vegetables. Providing a plate of fried foods does not align with effective nutritional instruction for a toddler's healthy development.
Choice C rationale
A scrambled egg provides a high-quality source of protein, essential for tissue growth and repair, along with healthy fats and vitamins like B12 and D. This choice indicates an understanding of the need for nutrient-dense foods in a toddler's diet. It is a suitable component of a balanced breakfast, especially when combined with other food groups like fruits or whole-grain toast.
Choice D rationale
Cake and ice cream are high in sugar and saturated fats, offering minimal nutritional value. Consuming these items for lunch is inconsistent with the principles of a balanced diet, which prioritizes nutrient-dense foods from all major food groups. This observation suggests the mother has not effectively implemented the dietary instructions provided by the nurse.
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