A nurse is caring for a 36-year-old female client in the labor and delivery unit at 39 weeks of gestation. The client has been admitted for evaluation of postpartum bleeding following a vaginal delivery of a viable newborn.
Select the 2 interventions the nurse should perform immediately.
Weigh the client’s perineal pad.
Insert a straight catheter for the client.
Administer methylergonovine 0.2 mg IM.
Draw a complete blood count.
Apply oxygen via nasal cannula.
Correct Answer : B,C
Choice A rationale: Weigh the client’s perineal pad: While weighing the perineal pad is helpful to estimate blood loss, it is not an immediate intervention that addresses the cause of the excessive bleeding or improves the client's condition in the moment.
Choice B rationale: Insert a straight catheter for the client: The client's fundus is deviated to the left and boggy, which can be due to a full bladder. Inserting a straight catheter can help empty the bladder, allowing the uterus to contract more effectively and reduce bleeding.
Choice C rationale: Administer methylergonovine 0.2 mg IM: Methylergonovine is a medication used to manage postpartum hemorrhage by stimulating uterine contractions. Given the client's excessive bleeding and boggy uterus, administering this medication can help improve uterine tone and reduce bleeding.
Choice D rationale: Draw a complete blood count: Drawing a complete blood count is useful for assessing the extent of blood loss and the client's overall condition, but it is not an immediate intervention that will directly address the excessive bleeding.
Choice E rationale: Apply oxygen via nasal cannula: Although oxygen can be beneficial for a client with significant blood loss to ensure adequate oxygenation, it does not directly address the cause of the excessive bleeding or improve uterine tone.
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Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A"}}
Explanation
|
Client Findings |
Placenta Previa |
Preterm Labor |
Abruptio Placentae |
|
Pain report |
X |
||
|
Uterine contractions |
X |
||
|
Perineal pad findings |
X |
X |
X |
|
Cervical dilation |
X |
- Pain report: The client reports low back pain and abdominal cramping, which can be associated with both preterm labor and abruptio placentae.
- Uterine contractions: Regular uterine contractions are a sign of preterm labor.
- Perineal pad findings: Bright red bleeding is consistent with all three conditions.
- Cervical dilation: Cervical dilation is a sign of preterm labor and placenta previa.
Correct Answer is C
Explanation
Choice A rationale
Oligohydramnios refers to low amniotic fluid levels and can lead to complications such as growth restriction and preterm birth. However, it is not a direct risk factor for postpartum hemorrhage, which involves excessive bleeding after childbirth due to uterine atony or retained placental fragments.
Choice B rationale
Breech presentation, where the baby's buttocks or feet are positioned to be delivered first, can increase the risk of complications during delivery but is not a primary risk factor for postpartum hemorrhage. Postpartum hemorrhage is more related to uterine issues and retained placental tissue.
Choice C rationale
Retained placental fragments are a significant risk factor for postpartum hemorrhage. If parts of the placenta remain in the uterus after delivery, they can prevent the uterus from contracting properly, leading to excessive bleeding. Immediate and effective management is essential to prevent severe hemorrhage.
Choice D rationale
Urinary tract infection (UTI) can lead to complications during pregnancy, such as preterm labor, but it is not directly associated with postpartum hemorrhage. Postpartum hemorrhage primarily results from uterine atony, trauma, retained placental tissue, and coagulopathy rather than infections.
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