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 D

Explanation

Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.

A. You have to avoid sexual relations for 3 days. B. If your sexual partner has no symptoms, no medication is needed. C. You need to return in 6 months for retesting. D. This infection is treated with one dose of erythromycin.

Correct Answer is C

Explanation

Choice A rationale
Avoiding sexual relations for 3 days is not sufficient advice for a client diagnosed with a sexually transmitted infection (STI). The client should abstain from sexual activity until they and their partner(s) have completed treatment and are symptom-free.
Choice B rationale
Even if a sexual partner has no symptoms, they could still be infected and require treatment. Many STIs can be asymptomatic, meaning they do not show symptoms, but can still be transmitted to others.
Choice C rationale
Returning in 6 months for retesting is a good practice for individuals diagnosed with an STI. Some infections, like chlamydia and gonorrhea, should be retested about 3 months after treatment. Other infections, like HIV, might need a follow-up test 6 months later to confirm the results.
Choice D rationale

The treatment for STIs varies depending on the specific infection. Not all STIs are treated with a single dose of erythromycin. For example, gonorrhea is typically treated with an injection of ceftriaxone and oral azithromycin.

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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

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Correct Answer is D

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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?