A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Palpate the client's uterine fundus.

Assist the client on a bedpan to urinate.

Prepare to administer oxytocic medication.

Increase the client's fluid intake.

Answer and Explanation

The Correct Answer is A

A. Palpating the client's uterine fundus is the priority intervention because excessive postpartum bleeding could indicate uterine atony, where the uterus fails to contract effectively. Assessing the fundus will help determine if it is boggy and if fundal massage is needed to promote uterine contraction and reduce bleeding.

B. Assisting the client to urinate is an important intervention if the bladder is distended, as a full bladder can prevent the uterus from contracting properly. However, palpating the fundus to assess the source of bleeding takes priority over assisting with urination.

C. Preparing to administer oxytocic medication may be necessary if the uterine fundus is boggy and does not respond to massage, but the first step is to assess the fundus and attempt manual intervention before proceeding with medication.

D. Increasing the client's fluid intake can help maintain circulation and prevent dehydration, but it does not address the immediate concern of postpartum hemorrhage. Palpating the fundus is the priority action in this scenario

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Correct Answer is A

Explanation

The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply

Choice A reason:

Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.

Choice B reason:

Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.

Choice C reason:

Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.

Choice D reason:

Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.

A. Hyporeactivity. B. Excessive high-pitched cry. C. Acrocyanosis. D. Respiratory rate of 50/min.

Correct Answer is B

Explanation

Choice A rationale:

Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.

Choice B rationale:

An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.

Choice C rationale:

Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.

Choice D rationale:

A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.

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A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

Correct Answer is B

Explanation

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