A nurse is caring for a client 2 hours following a spontaneous vaginal delivery and notes that the client has saturated
two perineal pads with blood in a 30-minute period.
Which of the following actions should the nurse take first?
Increase the client’s fluid intake
Check the consistency of the client’s uterine fundus
Help the client use the bedpan to urinate
Prepare to administer tocolytic medication
The Correct Answer is B
Choice A rationale:
Increasing fluid intake is not the priority action in this situation. While maintaining adequate hydration is important for
postpartum recovery, it does not directly address the immediate concern of excessive bleeding. Excessive fluid intake could
potentially worsen the bleeding by increasing blood volume and potentially increasing blood pressure.
Choice C rationale:
Helping the client use the bedpan to urinate is not the priority action in this case. While a full bladder can sometimes interfere
with uterine contraction and contribute to postpartum bleeding, it is not the most likely cause of the excessive bleeding in this
scenario. The client has already saturated two perineal pads in a short period, indicating a more significant bleeding issue that
needs to be addressed first.
Choice D rationale:
Preparing to administer tocolytic medication is not the appropriate action at this time. Tocolytic medications are used to stop
contractions, but they are not typically used to manage postpartum hemorrhage. In fact, tocolytics could potentially worsen
the bleeding by interfering with the natural mechanisms that help the uterus contract and stop bleeding after delivery.
Choice B rationale:
Checking the consistency of the client's uterine fundus is the priority action in this situation. The most common cause of
postpartum hemorrhage is uterine atony, which means the uterus is not contracting effectively to clamp down on the blood
vessels where the placenta was attached. A soft, boggy fundus is a sign of uterine atony. By assessing the fundus, the nurse can
quickly determine if uterine atony is the likely cause of the bleeding and take appropriate interventions to manage it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: A fundus that is firm and 4 fingerbreadths above the umbilicus 24 hours postpartum indicates uterine atony or retained placental fragments. This finding is not typical and may require further medical evaluation to prevent postpartum hemorrhage.
Choice B rationale: A soft fundus 2 fingerbreadths below the umbilicus suggests uterine atony, which can lead to postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract effectively after childbirth.
Choice C rationale: A soft fundus to the right of the umbilicus may indicate a full bladder pushing the uterus to one side. It can interfere with uterine contractions and should be addressed by encouraging the client to empty their bladder.
Choice D rationale: A firm fundus at 1 fingerbreadth below the umbilicus is the expected finding 24 hours postpartum. It indicates that the uterus is contracting well and returning to its pre-pregnancy size, reducing the risk of postpartum hemorrhage.
Correct Answer is C
Explanation
Choice A rationale:
The presence of a “bloody show” from the vagina is a normal part of labor. It’s caused by the expulsion of the mucus plug that
has sealed the cervix during pregnancy. This is a common occurrence and does not need to be reported to the provider.
Choice B rationale:
Early decelerations in the Fetal Heart Rate (FHR) are usually not a cause for concern. They are often a sign of head
compression, which is a normal occurrence during labor. Therefore, this finding does not need to be reported to the provider.
Choice C rationale:
Uterine contractions lasting 2 minutes could be a sign of a complication known as “uterine tachysystole” or “hyperstimulation”. This condition can reduce oxygen supply to the baby and may require medical intervention. Therefore, this finding should be reported to the provider.
Choice D rationale:
Feeling pelvic pressure with contractions is a normal part of the second stage of labor. This pressure is due to the baby moving
down into the birth canal. Therefore, this finding does not need to be reported to the provider.
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