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 A
Explanation
A. Administer the dose as ordered: In infants, digoxin is typically held if the apical heart rate is below 90–110 bpm. An apical rate of 114 bpm is above the threshold, so it is safe to administer the medication while continuing to monitor for signs of toxicity.
B. Hold the medication until the next dose: Holding digoxin unnecessarily can compromise therapeutic effectiveness and cardiac output, especially in infants with heart failure. Medication should only be held if the heart rate is below the established threshold.
C. Wait and recheck the apical heart rate in 30 minutes: Rechecking is unnecessary if the initial assessment shows a heart rate within safe limits. Delaying administration without cause may disrupt the medication schedule and its efficacy.
D. Notify the physician about the infant's heart rate: The heart rate is within an acceptable range for digoxin administration, so notifying the physician is not required in this instance. Routine monitoring and documentation are sufficient.
Correct Answer is C
Explanation
A. Oral contraceptives: Oral contraceptives regulate hormonal cycles to prevent ovulation and pregnancy but do not provide any barrier to infectious agents. They offer no protection against sexually transmitted infections (STIs), including HIV, chlamydia, or gonorrhea.
B. Tubal ligation: Tubal ligation is a permanent surgical method that blocks the fallopian tubes to prevent pregnancy. While highly effective for contraception, it does not prevent the transmission of sexually transmitted infections because it does not provide a barrier between partners.
C. Male or female condoms: Condoms act as a physical barrier preventing the exchange of bodily fluids during sexual activity, reducing the risk of pregnancy and transmission of STIs. Correct and consistent use significantly lowers exposure to pathogens such as HIV, HPV, chlamydia, and gonorrhea.
D. Intrauterine device: IUDs, whether hormonal or copper, provide long-term prevention of pregnancy by affecting implantation or sperm motility. They do not protect against STIs, as they do not prevent contact with infectious secretions during sexual activity.
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