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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Gestational hypertension is a condition characterized by elevated blood pressure during pregnancy. While it can increase the

risk of certain complications, it is not directly associated with an increased risk of postpartum hemorrhage. This is because

gestational hypertension primarily affects the vascular system, not the uterine muscle function, which is responsible for

controlling postpartum bleeding.

Choice B rationale:

A small for gestational age newborn (SGA) is a baby who is smaller than expected for their gestational age. While SGA can be

associated with some pregnancy complications, it is not a direct risk factor for postpartum hemorrhage. The size of the baby

does not have a significant impact on the ability of the uterus to contract and prevent excessive bleeding after delivery.

Choice C rationale:

Precipitous birth is defined as a labor that progresses very rapidly, with delivery occurring within three hours or less of the

onset of regular contractions. This rapid progression of labor can lead to postpartum hemorrhage for several reasons:

Uterine atony: The uterus may not have enough time to contract effectively after a rapid delivery, leading to increased

bleeding.

Lacerations and trauma: The rapid passage of the baby through the birth canal can increase the risk of tearing of the cervix,

vagina, or perineum, which can contribute to blood loss.

Retained placenta: The placenta may not separate from the uterine wall as easily after a precipitous birth, increasing the risk

of hemorrhage.

Choice D rationale:

A two-vessel umbilical cord is a variation in which the umbilical cord contains only two blood vessels (one vein and one

artery) instead of the usual three (one vein and two arteries). While this can be associated with certain fetal anomalies, it is not

a direct risk factor for postpartum hemorrhage. The number of blood vessels in the umbilical cord does not significantly

impact the ability of the uterus to contract and prevent bleeding after delivery.

A. Fever and chills. B. Increased heart rate. C. Lower abdominal pain. D. Unusual vaginal discharge.

Correct Answer is A

Explanation

Choice A rationale:

Fever: A hallmark sign of inflammation, fever is a common and often early manifestation of endometritis. The body's

thermostat, located in the hypothalamus, is reset to a higher temperature in response to infection or inflammation. This

triggers a cascade of physiological events, including chills, shivering, and increased heat production, as the body attempts to

fight off pathogens. In endometritis, the fever is typically 100.4°F (38°C) or higher.

Chills: Often accompanying fever, chills are a sensation of coldness despite a normal or elevated body temperature. They result

from involuntary muscle contractions, which generate heat in an attempt to raise the body's temperature. Chills can be mild or

severe, and they often precede a rise in temperature.

Choice B rationale:

Increased heart rate: Tachycardia, or an increased heart rate, can occur in endometritis, but it is not a specific finding. It can be

present in various other conditions, including anxiety, pain, dehydration, anemia, and other infections. While it may be a sign

of endometritis, it's not considered a primary manifestation.

Choice C rationale:

Lower abdominal pain: Lower abdominal pain is a common symptom in postpartum women, but it is not always indicative of

endometritis. It can result from uterine contractions, incisional pain (if a cesarean section was performed), bladder distention,

constipation, or other postpartum complications. While it may be present in endometritis, it's not a specific finding.

Choice D rationale:

Unusual vaginal discharge: Lochia, the normal postpartum vaginal discharge, can vary in color and amount. However, unusual

vaginal discharge, such as foul-smelling or purulent discharge, can be a sign of endometritis. It's important to note that not all

women with endometritis will have abnormal discharge.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago.The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Correct Answer is C

Explanation

A nurse is collecting data from a patient who gave birth one week ago.Which of the following findings should the nurse identify as a manifestation of endometritis?

Correct Answer is A

Explanation

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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?