A nurse is assisting with the care of a client who is experiencing a postpartum hemorrhage. Which of the following actions should the nurse take? (Select all that apply.).
Firmly massage the fundus.
Administer oxygen via a nonrebreather face mask.
Ensure the client has IV access.
Prepare the client for an amnioinfusion.
Correct Answer : A,B,C,E
Choice A reason:
The nurse should firmly massage the fundus. The rationale behind this action is that massaging the fundus helps to stimulate uterine contractions, which aids in controlling bleeding after childbirth. By promoting uterine contractions, the nurse can assist in preventing further hemorrhage.
Choice B reason:
The nurse should administer oxygen via a nonrebreather face mask. The rationale for this action is that postpartum hemorrhage can lead to decreased oxygen levels in the blood, which can be detrimental to both the mother and the baby. Providing oxygen via a nonrebreather face mask ensures adequate oxygenation and helps stabilize the client's condition.
Choice C reason:
The nurse should ensure the client has IV access. Establishing IV access is crucial in managing postpartum hemorrhage as it allows for the rapid administration of fluids, blood products, and medications. IV access ensures that the client receives prompt treatment to address the blood loss and stabilize her condition.
Choice D reason:
The nurse should not prepare the client for an amnioinfusion in the context of postpartum hemorrhage. An amnioinfusion is a procedure used during labor to infuse fluid into the amniotic sac. However, it is not indicated or relevant in the management of postpartum hemorrhage.
Choice E reason:
The nurse should give the client Rh (D) immune globulin. The rationale behind this action is that Rh (D) immune globulin, also known as RhoGAM, is administered to Rh-negative mothers after the birth of an Rh-positive baby. This prevents the mother's immune system from developing antibodies against Rh-positive blood cells, which could cause complications in future pregnancies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Washing off the zinc oxide ointment with each diaper change would not be beneficial for the infant's diaper dermatitis. Zinc oxide ointment forms a protective barrier on the skin, and frequent washing could remove this barrier, reducing its effectiveness in promoting healing and protecting the irritated skin.
Choice B reason:
Shaking talcum powder onto the reddened areas is not a suitable approach. Talcum powder can further irritate the skin and worsen the diaper dermatitis. It is best to avoid using talcum powder on an infant's delicate skin.
Choice C reason:
Using a hair dryer, even on the lowest setting, to dry the diaper area is not recommended. The hot air from the hair dryer can be too harsh for the infant's sensitive skin and might exacerbate the irritation. It is safer to let the diaper area air dry naturally or pat it gently with a soft cloth.
Choice D reason:
This is the correct choice. Using moist disposable wipes that are detergent-free is a suitable option for cleaning the infant's diaper area. Detergent-free wipes are gentle on the skin and less likely to cause further irritation. Additionally, keeping the area clean and dry is essential for managing diaper dermatitis, and these wipes can help achieve that without causing harm.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason:
Breast changes are considered a presumptive sign of pregnancy. This means they are subjective indications reported by the woman and may not be definitive evidence of pregnancy. During pregnancy, the woman's breasts may undergo various changes such as tenderness, enlargement, and darkening of the areolas. These changes are primarily due to hormonal fluctuations and increased blood flow to the breast tissue.
Choice B reason:
Ballottement is not a presumptive sign of pregnancy. Ballottement is a clinical maneuver performed by a healthcare provider to assess the mobility of the fetus in the amniotic fluid. It involves tapping on the cervix and feeling for a rebound from the floating fetus. While it is an indication of pregnancy, it is not considered a presumptive sign as it requires a trained professional to detect.
Choice C reason:
Urinary frequency is a presumptive sign of pregnancy. During pregnancy, the growing uterus can put pressure on the bladder, leading to increased urinary frequency. However, urinary frequency can also be caused by other factors such as urinary tract infections, so it is not a definitive sign of pregnancy.
Choice D reason:
Nausea, specifically morning sickness, is a presumptive sign of pregnancy. Many pregnant women experience nausea and vomiting, especially during the first trimester, due to hormonal changes. However, nausea can also be caused by various other conditions, making it a presumptive rather than a confirmatory sign of pregnancy.
Choice E:
A positive pregnancy test is a probable sign of pregnancy rather than a presumptive sign. Pregnancy tests detect the presence of human chorionic gonadotropin (hCG), a hormone produced during pregnancy. A positive test provides strong evidence of pregnancy, but it is not considered a presumptive sign as it is an objective finding rather than a subjective symptom reported by the woman.
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