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) Supine
Placing the newborn in the supine position (on their back) for sleep is recommended by pediatric guidelines to reduce the risk of sudden infant death syndrome (SIDS) and other sleep-related causes of infant death. The supine position allows for optimal airway patency and decreases the risk of suffocation. This position is safest for the newborn during sleep.
(b) Prone
Placing the newborn in the prone position (on their stomach) for sleep is not recommended due to an increased risk of SIDS. The prone position can obstruct the infant's airway and increase the risk of suffocation or overheating, leading to adverse outcomes.
(c) Left lateral
While placing the newborn on the left side may be recommended for certain medical procedures or interventions, such as feeding to reduce reflux, it is not recommended for sleep positioning. Placing the newborn in the left lateral position during sleep does not provide the same benefits for airway patency and SIDS risk reduction as the supine position.
(d) Right lateral
Similar to the left lateral position, placing the newborn on the right-side during sleep does not offer the same protective benefits as the supine position. It does not reduce the risk of SIDS and may pose similar risks as the prone position, such as airway obstruction.
Correct Answer is D
Explanation
(a) "You will not be able to eat or drink anything for 8 hours prior to the test."
There are no fasting requirements for a nonstress test. The client can eat and drink normally before the test. Nonstress tests do not require the same preparation as some other medical tests, such as fasting or dietary restrictions.
(b) "You will be required to lie flat on your back for the duration of the test."
Lying flat on the back can cause supine hypotension syndrome in pregnant women, which can lead to decreased blood flow to the fetus. Instead, clients are typically positioned in a semi-Fowler's or lateral position to avoid this issue.
(c) "You will receive medication through an IV line to stimulate contractions."
This describes a contraction stress test, not a nonstress test. A nonstress test involves monitoring the fetal heart rate in response to natural fetal movements without inducing contractions through medication.
(d) "You will press the provided button when you feel the baby moving during the test."
During a nonstress test, the client is instructed to press a button whenever they feel fetal movement. This helps the healthcare provider correlate fetal movements with changes in the fetal heart rate, which can indicate fetal well-being.
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