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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Kale is an excellent non-dairy source of calcium. Dark leafy greens like kale are rich in calcium, with approximately 90 mg of calcium per cup when cooked. Including kale in the diet can help pregnant women meet their calcium needs, especially if they do not consume dairy products.
(B) 1 baked potato:
While potatoes are a source of several nutrients, including potassium and vitamin C, they are not significant sources of calcium. Therefore, a baked potato would not be the best recommendation for meeting calcium needs in a client who does not consume dairy products.
(C) 1 large banana:
Bananas are nutritious fruits containing potassium and vitamin C, but they are not significant sources of calcium. Therefore, while bananas are a healthy food choice during pregnancy, they would not provide sufficient calcium for someone who does not consume dairy products.
(D) 1 cup sweet white corn:
Sweet white corn is a tasty vegetable rich in vitamins and minerals, but it is not a significant source of calcium. Therefore, while it can contribute to overall nutritional intake during pregnancy, it would not be the best recommendation for meeting calcium needs in a client who does not consume dairy products.
Correct Answer is C
Explanation
(A) Lie in a left side lying position for 30 min after meals:
While lying on the left side can sometimes help alleviate heartburn, it's generally recommended to elevate the head and upper body during sleep, especially if heartburn worsens at night. Lying down immediately after meals can actually exacerbate heartburn symptoms.
(B) Drink a cup of black coffee before breakfast:
Drinking black coffee can exacerbate heartburn symptoms due to its acidic nature and caffeine content. It is not recommended for individuals experiencing frequent heartburn, especially during pregnancy.
(C) Take sips of milk between meals:
Taking sips of milk between meals can help neutralize stomach acid and provide temporary relief from heartburn symptoms. However, it's essential to avoid drinking large quantities of milk at once, as this can lead to increased stomach acid production.
(D) Eat three large meals per day:
Eating large meals can increase pressure on the stomach and exacerbate heartburn symptoms. Instead of consuming three large meals, it's better to eat smaller, more frequent meals throughout the day to help prevent heartburn.
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