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 A
Explanation
A.
Rationale:
A. Administering oxygen helps improve oxygenation to the fetus and is the priority intervention for late decelerations.
B. Amnioinfusion may be considered for variable decelerations caused by oligohydramnios but is not indicated for late decelerations.
C. Instructing the client to bear down and push with contractions is not appropriate for addressing late decelerations and may worsen fetal distress.
D. Placing the client in a supine position can exacerbate late decelerations by reducing blood flow to the uterus and should be avoided.
Correct Answer is C
Explanation
Rationale:
A. Instructing the client about an autopsy is not the immediate priority and may not be appropriate at this sensitive time.
B. Informing the client about the law regarding naming the fetus is not a priority and may add unnecessary stress to the situation.
C. Providing photos of the fetus is the most appropriate action since it minimzes the trauma to the mother while providing closures.
D. Limiting the amount of time the fetus is in the client's room is not appropriate as when the mother needs more time with the fetus, she hsould be allowed to provide for closure
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