A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.
What action should the nurse take first?

Call the healthcare provider.

Encourage the client to void.

Administer ibuprofen 800 mg by mouth.

Increase the intravenous fluid to 150 mL/hour.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.

Choice B rationale

Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.

Choice C rationale

Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.

Choice D rationale

Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client’s heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.

Choice B rationale

While monitoring urinary output and IV fluid intake can be important in the overall assessment of a postpartum client, these are not the most immediate concerns when a perineal hematoma is forming.

Choice C rationale

Checking hemoglobin and hematocrit levels can provide information about the client’s blood volume and potential blood loss. However, this would likely be done after initial vital signs are assessed and stabilized.

Choice D rationale

Assessing abdominal contour and bowel sounds would not be the most immediate concern in this situation. These assessments would be more relevant if there were concerns about postpartum complications related to the client’s gastrointestinal system.

A. Heat loss. B. Hypoglycemia. C. Fluid balance. D. Bleeding tendencies.

Correct Answer is A

Explanation

Choice A rationale

Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss.

Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.

Choice B rationale

While hypoglycemia is a concern in newborns, especially those born to mothers with diabetes, it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice C rationale

Fluid balance is important in newborns, but it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice D rationale

While newborns do have immature clotting mechanisms, making them more prone to bleeding tendencies, this is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

Correct Answer is A

Explanation

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.What priority issue should the nurse address to ensure the newborn’s survival?

Correct Answer is A

Explanation

The nurse is providing preconception counseling.Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.What action should the nurse take first?

A client with gestational diabetes is scheduled for an amniocentesis due to the fetus weighing an estimated 8 pounds (3629 grams) at 36-weeks gestation.What information is being sought through this amniocentesis?

A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.Which assessment action should the nurse prioritize?

What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.
What action should the nurse take first?