A nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which of the following would be the initial nursing action?
Record the findings
Notify the HCP
Massage the fundus
Place the client in Trendelenberg's position
The Correct Answer is C
A. Record the findings: Documentation is important, but it does not address the immediate cause of excessive bleeding. Active assessment and intervention are required before charting when postpartum hemorrhage is suspected.
B. Notify the HCP: Provider notification is appropriate if initial nursing interventions fail, but priority is to address the most common reversible cause first. Early nursing actions can often correct the problem and reduce severity.
C. Massage the fundus: Excessive bleeding with a firm fundus suggests retained clots within the uterus preventing adequate contraction. Fundal massage helps expel clots, promotes uterine contraction, and directly reduces postpartum bleeding.
D. Place the client in Trendelenburg’s position: Trendelenburg positioning does not correct uterine bleeding and may worsen maternal discomfort or respiratory status. Positioning alone does not address the underlying uterine or placental cause of hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Flex her knee while resting: Flexing the knee repeatedly can increase venous stasis and may worsen symptoms if a deep vein thrombosis (DVT) is present. It is not recommended in suspected thromboembolic events.
B. Massage the area: Massaging a calf with pain and redness in the postpartum period can dislodge a thrombus and cause a potentially life-threatening pulmonary embolism. This intervention is contraindicated.
C. Elevate her leg: Elevating the affected leg promotes venous return, reduces swelling, and can help alleviate discomfort. It is a safe supportive measure while awaiting evaluation by a healthcare provider.
D. Apply cold compress: Cold compresses are generally used for acute inflammation or trauma. In suspected DVT, cold application does not address the underlying venous obstruction and is not a priority intervention.
Correct Answer is D
Explanation
A. Herpes: Genital herpes is caused by herpes simplex virus (HSV) and is a lifelong viral infection. Antiviral medications can manage outbreaks and reduce transmission but cannot cure the infection.
B. Acquired imunodeficiency syndrome (AIDS): AIDS is caused by HIV, which is a chronic viral infection. Antiretroviral therapy controls viral replication and improves immune function but does not eradicate the virus.
C. Venereal warts: Caused by human papillomavirus (HPV), genital warts can be treated or removed, but the underlying viral infection may persist. Recurrence is common, and no definitive cure exists.
D. Chlamydia: Chlamydia trachomatis is a bacterial infection that can be effectively treated and cured with antibiotics such as azithromycin or doxycycline when the full course is completed, preventing long-term complications.
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