A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.

What should the nurse do first?

Administer Oxytocin to the client

Massage the client’s fundus

Provide oxygen to the client via non-rebreather face mask

Empty the client’s bladder

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering Oxytocin to the client is an important intervention for postpartum hemorrhage, but it is not the first action the nurse should take. Oxytocin stimulates uterine contractions which can help control bleeding, but it should be administered after the initial steps of assessing the uterus and ensuring it is firm.
Choice B rationale
Massaging the client’s fundus is the priority action to address excessive vaginal bleeding. A firm, well-contracted uterine fundus often helps to control postpartum bleeding. If the uterus is not well contracted, gentle massage is often sufficient to stimulate contractions. If the uterus does not respond to massage, then further interventions such as administering Oxytocin may be necessary.
Choice C rationale
Providing oxygen to the client via a non-rebreather face mask is an intervention that might be necessary if the client shows signs of hypoxia or shock as a result of the bleeding. However, it is not the first action that should be taken.
Choice D rationale
Emptying the client’s bladder is important as a distended bladder can displace the uterus and interfere with contractions, leading to increased bleeding. However, this is not the first action to take.

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Correct Answer is A

Explanation

Choice A rationale
Placenta previa is a condition where the placenta partially or completely covers the cervix. Vaginal bleeding, often without pain, is a key symptom and requires immediate medical attention.
Choice B rationale
While a fetal heart rate of 174 bpm is slightly above the normal range (110-160 bpm), it is not the most critical finding in a patient with complete placenta previa.
Choice C rationale
A fundal height of 33 cm at 32 weeks of gestation is within the expected range and does not require immediate follow-up.
Choice D rationale
An abdomen that is soft and non-tender is a normal finding and does not require immediate follow-up.

A. Provide a stimulating environment B. Monitor blood glucose level every hour C. Initiate seizure precautions D. Place the infant on his back with legs extended

Correct Answer is C

Explanation

Choice A rationale
Providing a stimulating environment is not recommended for infants with neonatal abstinence syndrome (NAS). These infants often have a heightened response to stimuli, and a calm, quiet environment is usually more beneficial.
Choice B rationale
While it is important to monitor the infant’s overall health, there is no specific need to monitor blood glucose level every hour in infants with NAS unless there is a separate medical indication.
Choice C rationale
Initiating seizure precautions is an appropriate action for a nurse caring for an infant with signs of NAS5. Infants with NAS are at risk for seizures, so nurses should be prepared to manage this potential complication.
Choice D rationale
Placing the infant on his back with legs extended is not recommended. Infants with NAS often have increased muscle tone and may be uncomfortable in this position.

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A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

“A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”

Correct Answer is A

Explanation

A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding.

What should the nurse do first?