A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.

Which of the following actions should the nurse take first?

Collect hemoglobin and hematocrit levels.

Insert an indwelling urinary catheter.

Administer oxygen via face mask at 10 L/min.

Prepare the client to receive a plasma expander.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.

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Correct Answer is D

Explanation

Choice A rationale:
Uterine hypertonicity is associated with labor complications, not placenta previa.
Choice B rationale:
A persistent headache is not a typical symptom of placenta previa.
Choice C rationale:
A firm, rigid abdomen is a sign of a possible uterine rupture, not placenta previa.
Choice D rationale:
Painless, vaginal bleeding is a classic symptom of placenta previa, so this statement is correct.

A. The client is changing the perineal pad once daily. B. The client is using witch hazel pads on the perineum. C. The client cleans the perineum with a squeeze bottle after urinating. D. The client's perineal suture line is well-approximated.

Correct Answer is A

Explanation

Choice A rationale:
Changing the perineal pad once daily could lead to infection, which would delay wound healing.
Choice B rationale:
Witch hazel pads are often used for their soothing and anti-inflammatory properties, which can aid in healing.
Choice C rationale:
Cleaning the perineum with a squeeze bottle after urinating helps to keep the area clean and promote healing.
Choice D rationale:
A well-approximated suture line indicates that the wound edges are close together, which is conducive to healing.

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A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.

Which of the following actions should the nurse take first?