A nurse admits a normal vaginal delivery to the maternity unit 2 hours ago.
The patient's fundus is firm at the umbilicus.
On admission, her vital signs are BP 108/64, Apical 90, RR 20, and Temp.
98.6°F. Suddenly, her lochia appears to be heavy, saturating the entire chux pad within 5 minutes.
At this time, the nurse's first priority action is:
Place the patient in a Trendelenburg position.
Notify the physician on call about the emergency.
Administer Methylergonovine 0.2 mg IM now.
Massage fundus until firm.
The Correct Answer is D
Choice A rationale
Placing the patient in a Trendelenburg position is not the immediate priority. This position is often used to manage shock or to improve blood flow to the brain, but it does not directly address the cause of heavy lochia. It may not be the most effective first intervention in this situation.
Choice B rationale
Notifying the physician is important, but the nurse should first attempt to control the bleeding. The physician can be notified after initial measures to stop the bleeding are taken. Immediate intervention by the nurse is crucial in this scenario to stabilize the patient.
Choice C rationale
Administering Methylergonovine can help control postpartum hemorrhage, but this should be done after attempting non-pharmacological measures like fundal massage. Methylergonovine can have side effects and should be used with caution.
Choice D rationale
Massaging the fundus until it is firm is the immediate priority. This can help expel clots and stimulate uterine contraction, which can reduce bleeding. It is a direct and immediate intervention to address the heavy lochia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Infants born at 40 weeks gestation typically have increased subcutaneous fat, aiding in temperature regulation and energy reserves.
Correct Answer is C
Explanation
Choice A rationale
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Normal neonatal glucose: >45 mg/dL (ideally 50–110 mg/dL).
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A level of 40 is low → risk for hypoglycemia complications (seizures, brain injury).
While it is important to monitor glucose levels, a reading of 40 mg/dL is low and requires immediate attention. Waiting 4 hours could allow the newborn's condition to deteriorate further. Hypoglycemia in newborns can lead to serious complications if not treated promptly.
Choice B rationale
Assessing for hypothermia is essential, but it is not the first priority when a newborn has low blood glucose levels. Immediate steps should be taken to address the hypoglycemia to prevent further complications, as it is a more immediate threat to the newborn's health.
Choice C rationale
Notifying the physician on call is the correct priority intervention. A blood glucose level of 40 mg/dL is concerning, and prompt medical intervention is necessary. The physician can order appropriate treatment to stabilize the newborn's glucose levels and prevent potential complications.
Choice D rationale
Re-evaluating the blood serum glucose is important but comes after initiating immediate intervention. Continuous monitoring should follow initial treatment to ensure the newborn's glucose levels stabilize. Immediate action is crucial to address the hypoglycemia effectively.
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