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.
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Related Questions
Correct Answer is D
Explanation
(A) Restrict fluids to 1,000 mL/day:
Restricting fluids may lead to dehydration, which can exacerbate nausea and other symptoms of morning sickness. It is important for pregnant individuals to stay hydrated, so fluid restriction is not recommended unless otherwise directed by a healthcare provider.
(B) Take an over-the-counter antacid:
While antacids may provide relief for heartburn or indigestion, they are not typically recommended as a first-line treatment for nausea associated with morning sickness. Antacids may have limited effectiveness in managing nausea, and their use should be guided by a healthcare provider.
(C) Increase intake of fresh fruits:
While fresh fruits are nutritious and provide essential vitamins and minerals, they may not be well-tolerated by individuals experiencing morning sickness, especially if they have strong flavors or odors. Encouraging the client to eat bland foods in the morning may be more effective in managing nausea during early pregnancy.
(D) Eat dry, bland foods in the morning:
Encouraging the client to eat dry, bland foods in the morning can help alleviate nausea associated with morning sickness. These foods are generally easier on the stomach and less likely to trigger nausea compared to richer or spicier foods. Examples include crackers, toast, or dry cereal. Eating small, frequent meals throughout the day can also help manage nausea associated with pregnancy.
Correct Answer is C
Explanation
(a) "You will need to receive a medroxyprogesterone acetate injection once per month."
Medroxyprogesterone acetate injections (Depo-Provera) are administered every three months (every 12 weeks), not monthly. This statement is incorrect and could lead to confusion about the correct usage of this contraceptive method.
(b) "Combined estrogen-progestin contraceptive pills cause longer periods."
Combined estrogen-progestin contraceptive pills typically result in shorter, lighter, and more regular periods, rather than longer ones. This statement is incorrect and misrepresents the effects of combined oral contraceptives on menstrual cycles.
(c) "Oral contraceptives decrease the risk for endometrial cancer."
This statement is correct. Oral contraceptives, particularly those containing both estrogen and progestin, are known to decrease the risk of endometrial cancer. This is an important benefit of using oral contraceptives and is a factual statement that should be included in the teaching.
(d) "You will need to have your diaphragm replaced every 4 years."
A diaphragm typically needs to be replaced every 2 years, not every 4 years. Additionally, a diaphragm should be refitted if there are significant changes in weight, childbirth, or abdominal/pelvic surgery. This statement is incorrect regarding the replacement timeline.
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