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) "White blood cell count is an indicator of anemia.”
White blood cell count is not directly related to anemia. Anemia is typically assessed by hemoglobin and hematocrit levels, which reflect the oxygen-carrying capacity of the blood. White blood cell count measures immune system function and can indicate infection or inflammation rather than anemia.
(B) "Urine specific gravity identifies my risk for pregnancy induced hypertension.”
Urine specific gravity is a measure of urine concentration and hydration status, and it is not typically used to identify the risk of pregnancy-induced hypertension (preeclampsia). Preeclampsia is diagnosed based on symptoms such as hypertension (high blood pressure) and proteinuria (protein in the urine), along with other criteria.
(C) "Platelet count identifies if I am at risk for bleeding.”
Platelet count is a laboratory test that measures the number of platelets in the blood. Platelets are essential for blood clotting, so a low platelet count (thrombocytopenia) can indicate an increased risk of bleeding, which is pertinent to pregnancy, especially in cases of conditions like gestational thrombocytopenia or preeclampsia.
(D) "Sedimentation rate checks for signs of cancer.”
The sedimentation rate (ESR or sed rate) is a nonspecific test that measures inflammation in the body, but it is not used to check for signs of cancer specifically. Elevated sedimentation rate can indicate various inflammatory conditions such as infection, autoimmune diseases, or chronic inflammatory disorders. It is not a primary test for cancer diagnosis.
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