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 A
Explanation
Choice A rationale:
2+ patellar reflex: A hyperactive patellar reflex (also known as a knee-jerk reflex) is a sign of hyperreflexia, which can be a neurological symptom of preeclampsia. Hyperreflexia results from heightened nerve excitability and can manifest as exaggerated reflexes. In preeclampsia, it stems from central nervous system irritability due to cerebral edema or other neurological disturbances.
2+ proteinuria: Proteinuria, defined as the presence of excessive protein in the urine, is a hallmark sign of preeclampsia. It indicates glomerular damage in the kidneys, leading to protein leakage into the urine. The degree of proteinuria is graded on a scale of 1+ to 4+, with 2+ representing a significant level that warrants immediate attention.
Choice B rationale:
24 weeks of gestation: While 24 weeks of gestation is considered early preterm birth, it is not inherently a finding that requires immediate reporting to the RN in the context of postpartum care. The focus on the postpartum unit is primarily on the health of the mother and newborn after delivery, rather than managing ongoing pregnancies.
Choice C rationale:
Preeclampsia: While preeclampsia is a serious condition that necessitates close monitoring and management, the mere diagnosis of preeclampsia without additional concerning findings does not automatically require immediate reporting to the RN. It's essential to assess for specific signs and symptoms that indicate worsening or complications of preeclampsia, such as those mentioned in Choice A.
Choice D rationale:
Heart rate of 100/min: A heart rate of 100 beats per minute is within the normal range for adults, even postpartum. Mild tachycardia (increased heart rate) can be a physiological response to various factors such as pain, anxiety, or exertion, and it does not always signify a serious problem. However, if the heart rate is persistently elevated or accompanied by other concerning symptoms, it would warrant further evaluation.
Correct Answer is A
Explanation
Choice A rationale:
A full bladder can displace the uterus to the right and interfere with its ability to contract properly. This can lead to
postpartum hemorrhage, a serious complication that can occur after childbirth.
Emptying the bladder helps to reposition the uterus in the midline and allows it to contract more effectively. This helps to
prevent postpartum hemorrhage and promotes uterine involution, the process by which the uterus returns to its pre-
pregnancy size.
In this case, the client's fundus is firm, which indicates that it is contracting well. However, it is slightly deviated to the right,
which suggests that the bladder may be full.
Asking the client to empty her bladder is a simple and effective way to address this potential problem.
Choice B rationale:
Repeating the client's temperature evaluation is not a priority action in this case. The client's vital signs are within normal
limits, and there is no indication of infection.
A temperature elevation could be a sign of infection, but it is not the most likely cause of the uterine deviation in this case.
Choice C rationale:
Encouraging the client to nurse more frequently may be helpful in stimulating milk production and uterine contractions.
However, it is not the most immediate priority in this case.
The client's breasts are soft, which suggests that she is not yet producing a significant amount of milk.
The priority is to address the potential problem of a full bladder, which could interfere with uterine involution.
Choice D rationale:
Checking for signs of a urinary tract infection is not a priority action in this case. The client does not have any urinary
symptoms, such as dysuria or frequency.
A urinary tract infection could cause a uterine deviation, but it is not the most likely cause in this case.
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