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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ovulation will indeed remain the same after a tubal ligation. The procedure involves blocking or sealing the fallopian tubes, which prevents the egg from reaching the uterus. However, the ovaries continue to release eggs.
Choice B rationale
A tubal ligation procedure does not affect the length of the menstrual period. The menstrual cycle is regulated by hormones, not the patency of the fallopian tubes.
Choice C rationale
Premenstrual tension or premenstrual syndrome (PMS) is not eliminated by tubal ligation. PMS is related to the hormonal changes that occur during the menstrual cycle.
Choice D rationale
Hormone replacements are not needed following a tubal ligation. The ovaries continue to produce hormones as they did before the procedure.
Correct Answer is C
Explanation
To calculate the estimated date of delivery using Nägele’s Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. This gives an estimated date of delivery of May 176.
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