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 B
Explanation
Rationale:
A. Gestational diabetes mellitus is not a contraindication for a contraction stress test. In fact, clients with gestational diabetes may require additional fetal monitoring due to the increased risk of fetal complications.
B. A previous classical incision, also known as a vertical uterine incision, increases the risk of uterine rupture during labor, making a contraction stress test contraindicated.
C. A previous stillbirth is not a contraindication for a contraction stress test. In fact, it may prompt additional fetal monitoring to assess for potential complications in subsequent pregnancies.
D. A nonreactive nonstress test may indicate the need for further evaluation with a contraction stress test; it is not a contraindication in itself.
Correct Answer is B
Explanation
Rationale:
A. Determining the client's apical pulse rate is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
B. Asking the client if they are taking the medication as prescribed is a direct way to evaluate medication adherence. Open communication with the client can provide valuable insight into their medication-taking behavior.
C. Assessing the client's kidney function is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
D. Checking the client's serum medication level can provide information about medication concentration but may not necessarily indicate adherence, as the level could be within the therapeutic range even if the client is not taking the medication as prescribed.
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