A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period.
What should be the priority nursing intervention at this time?

Prepare to administer oxytocic medication.

Assist the client on a bedpan to urinate.

Palpate the client’s uterine fundus.

Increase the client’s fluid intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Administering oxytocic medication is an intervention that may be necessary if the client’s bleeding does not stop or if the uterus does not contract adequately. However, the priority is to assess the situation, which includes palpating the uterine fundus.
Choice B rationale
Assisting the client on a bedpan to urinate can help if the bladder is full and preventing the uterus from contracting properly. However, the priority is to assess the uterus by palpating the uterine fundus.
Choice C rationale
Palpating the client’s uterine fundus is the priority nursing intervention. A boggy uterus (one that does not contract properly) is a common cause of postpartum hemorrhage. If the uterus is not firm upon palpation, massage it until it firms up.
Choice D rationale
Increasing the client’s fluid intake can help replace lost fluids, but it is not the priority intervention. The first step is to assess the cause of the bleeding, which includes palpating the uterine fundus.

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Correct Answer is C

Explanation

Choice A rationale
Elevating the client’s legs is not the first action to take. While it can help with circulation, it does not directly address the issue of late decelerations.
Choice B rationale
Administering oxygen using a nonrebreather mask can be beneficial as it can increase the amount of oxygen available to the fetus. However, it is not the first action to take.
Choice C rationale
Placing the client in the lateral position is the correct action. This position can help improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Increasing the rate of maintenance IV infusion is not the first action to take. While it can help maintain hydration and blood pressure, it does not directly address the issue of late decelerations.

A. Babinski. B. Stepping. C. Rooting. D. Moro.

Correct Answer is C

Explanation

Choice A rationale
The Babinski reflex is a normal reflex in infants that disappears by 12 months of age. It involves fanning out of the toes when the sole of the foot is stroked, and it doesn’t promote latching during breastfeeding.
Choice B rationale
The stepping reflex is a primitive reflex that makes newborns appear to take steps or dance when held upright with their feet touching a solid surface. It doesn’t promote latching during breastfeeding.
Choice C rationale
The rooting reflex helps promote latching during breastfeeding. When the corner of the baby’s mouth is touched, the baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Choice D rationale
The Moro reflex, also known as the startle reflex, involves the baby throwing back his or her head, extending out the arms and legs, crying, then pulling the arms and legs back in. It doesn’t promote latching during breastfeeding.

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A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period. What should be the priority nursing intervention at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch?

Correct Answer is C

Explanation

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A nurse is attending to a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood within a 30-minute period.
What should be the priority nursing intervention at this time?