A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes. Which of the following actions is the highest priority?
Perform fundal massage
Weigh the perineal pad
Apply oxygen by face mask
Monitor urine output
The Correct Answer is A
(A) Perform fundal massage:
Performing fundal massage is the highest priority action in this scenario. Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, which could indicate postpartum hemorrhage (PPH). Fundal massage helps to stimulate uterine contractions, which can aid in controlling bleeding by compressing blood vessels at the placental site. It is essential to assess the fundus for firmness and position and massage it if necessary, to prevent or manage PPH.
(B) Weigh the perineal pad:
Weighing the perineal pad can provide information about the amount of blood loss, but it is not the highest priority action at this moment. Fundal massage takes precedence to address the potential underlying cause of excessive bleeding.
(C) Apply oxygen by face mask:
While oxygen therapy may be indicated in certain situations, such as respiratory distress, it is not the highest priority in this scenario. The priority is to address the potential cause of excessive bleeding and prevent further complications associated with postpartum hemorrhage.
(D) Monitor urine output:
Monitoring urine output is an important aspect of postpartum care, but it is not the highest priority when the client is experiencing excessive bleeding. Addressing the potential cause of bleeding and preventing complications associated with postpartum hemorrhage take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
(A) Urination urgency and frequency:
Increased urgency and frequency of urination are common discomforts during the first trimester of pregnancy. This occurs due to hormonal changes and the growing uterus pressing on the bladder, which reduces its capacity.
(B) Tingling in the fingers:
Tingling in the fingers, also known as carpal tunnel syndrome, is more commonly associated with the later stages of pregnancy when fluid retention is more pronounced. It is not typically a common discomfort during the first trimester.
(C) Round ligament pain:
Round ligament pain is more common in the second trimester when the uterus is growing rapidly and the ligaments supporting it stretch. This type of pain usually manifests as sharp, shooting pain in the lower abdomen or groin.
(D) Perineal discomfort and pressure:
Perineal discomfort and pressure are more common in the later stages of pregnancy, particularly in the third trimester, as the baby descends into the pelvis and prepares for birth. It is not typically a discomfort experienced during the first trimester.
Correct Answer is A
Explanation
(A) "You should recognize that your baby sucking on his hands is a hunger cue.":
This statement is correct because babies often show early hunger cues such as sucking on their hands, rooting (turning their head towards the breast or bottle), or making sucking noises. Recognizing these early signs helps ensure that the baby is fed before they become too hungry and upset, making breastfeeding easier and more successful.
(B) "You should feed your baby for 10 minutes on each breast.":
This statement is not entirely accurate because the duration of feeding can vary widely among babies. Some babies may need more time to feed, while others may need less. It's important to allow the baby to feed until they show signs of being satisfied, such as slowing down their sucking or releasing the breast on their own.
(C) "You should feed your baby six times a day.":
Newborns typically need to be fed more frequently than six times a day, often every 2-3 hours, which can amount to 8-12 times in 24 hours. Feeding on demand, rather than following a strict schedule, ensures that the baby gets enough milk and supports the mother's milk supply.
(D) "You should wake your baby at least every 6 hours at night for feedings.":
This statement is not recommended because newborns, especially in the first few weeks, usually need to be fed more frequently than every 6 hours, even at night. It's generally advised to wake the baby for feedings every 3-4 hours if they do not wake up on their own to ensure they receive enough nutrition and maintain adequate growth and hydration
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