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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Question: Estimated due date using Nägele’s Rule.
Step 1: Add 7 days to the first day of the last menstrual period. May 4 + 7 days = May 11
Step 2: Subtract 3 months from the result. May 11 - 3 months = February 11
Step 3: Add 1 year to the result. February 11 + 1 year = February 11, 2024
Answer: February 11, 2024
Correct Answer is C
Explanation
Continuous contractions lasting 2 minutes could indicate uterine tetany, which could lead to uterine rupture, a life-threatening situation that requires immediate medical attention.
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