A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
Massage the client's fundus.
Empty the client's bladder.
Provide oxygen to the client via nonrebreather face mask.
Administer oxytocin to the client.
The Correct Answer is A
A.
Rationale:
A. Massaging the client's fundus is the priority action to address excessive vaginal bleeding.
Massaging the fundus helps promote uterine contractions, which can help control bleeding by compressing blood vessels.
B. Emptying the client's bladder may be necessary to relieve pressure on the uterus, but it is not the first priority when addressing excessive bleeding.
C. Providing oxygen may be indicated if the client shows signs of hypoxia, but it is not the first action to address excessive vaginal bleeding.
D. Administering oxytocin may be necessary to help control bleeding, but massaging the fundus is the first step in managing postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,B,D,E
Explanation
C. Instruct the client to empty their bladder.
A. Position the client supine with knees flexed and place a small rolled towel under one of their hips.
B. Palpate the fetal part positioned in the fundus.
D. Palpate the fetal parts along both sides of the uterus.
E. Palpate the fetal part positioned above the symphysis pubis.
Correct Answer is B
Explanation
Rationale:
A. Inserting a urinary catheter is an invasive procedure and should not be the first action taken to address bladder distention following a vaginal birth. It should only be considered if the client is unable to void voluntarily.
B. Assisting the client to the bathroom is the initial intervention to attempt to relieve bladder distention. Encouraging the client to void in a comfortable and familiar environment may stimulate urination and help alleviate the distention.
C. Offering the client a sitz bath may provide comfort and promote perineal healing but is not the first intervention for bladder distention.
D. Pouring warm water over the client's perineum may also provide comfort but does not directly address bladder distention.
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