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 ["A","D"]
Explanation
Choice A rationale
The client understanding the importance of monitoring their incision for signs of infection, such as discharge, indicates effective teaching. It is crucial for the client to report any changes to their healthcare provider promptly.
Choice B rationale
Having a fever during the first week at home is not a normal postoperative symptom and could indicate an infection. Therefore, this statement does not indicate effective teaching.
Choice C rationale
Resting in a recliner until the incision is healed is not necessary. While it’s important for the client to rest and recover after surgery, they should also engage in light physical activity, such as walking, to promote circulation and prevent complications such as blood clots.
Choice D rationale
The client should not have unrelieved pain in their abdomen. Persistent pain could indicate a complication, such as an infection or a hematoma. Therefore, this statement indicates effective teaching.
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a lateral position can help improve blood flow to the uterus and placenta, which can help stabilize the client’s blood pressure and the fetal heart rate.
Choice B rationale
Monitoring vital signs every 5 minutes is important, but the priority action is to address the client’s low blood pressure, which can compromise blood flow to the fetus.
Choice C rationale
Elevating the client’s legs can help increase venous return and improve blood pressure, but it is not the priority action in this situation.
Choice D rationale
Notifying the provider is important, but the nurse should first take action to stabilize the client’s condition.
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