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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The nurse should ask the client if they are taking over-the-counter medications because ibuprofen is also available over-the-counter. It is important to know if the client is already taking ibuprofen or any other non-prescription pain relievers to avoid potential drug interactions or overdosing.
Choice B rationale:
The nurse should inquire about the client's history of gastric problems because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation and bleeding. If the client has a history of gastric ulcers or other gastric issues, the nurse may need to consider an alternative pain relief option.
Choice C rationale:
The question about contraception is not directly related to administering ibuprofen for postpartum cramping. It is essential to provide adequate pain relief, but the method of contraception the client plans to use is not relevant to the administration of the medication.
Choice D rationale:
This question is pertinent because NSAIDs like ibuprofen can cause fluid retention and potentially worsen hypertension.
Choice E rationale:
The presence of cataracts is not relevant to the administration of ibuprofen for postpartum cramping. Cataracts are a concern with eye health and are not associated with taking this pain medication.
Correct Answer is A
Explanation
Choice A rationale:
Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use are indicative of abruptio placentae. Abruptio placentae is a medical emergency where the placenta detaches from the uterine wall before delivery, leading to severe bleeding and abdominal pain. Immediate medical intervention is necessary to prevent complications for both the mother and the baby.
Choice B rationale:
Hydatidiform mole is a gestational trophoblastic disease that occurs due to an abnormal pregnancy. It is not associated with continuous abdominal pain and vaginal bleeding. Instead, clients with this condition often present with vaginal bleeding and a grape-like cluster of cysts in the uterus.
Choice C rationale:
Preterm labor involves regular uterine contractions and cervical changes before 37 weeks of gestation. While preterm labor can cause abdominal discomfort, it is not usually described as continuous abdominal pain. Vaginal bleeding is not a typical symptom of preterm labor.
Choice D rationale:
Placenta previa is a condition where the placenta covers the opening of the cervix. It can cause painless vaginal bleeding, but it is not usually associated with continuous abdominal pain. Clients with placenta previa often experience sudden, painless bleeding later in pregnancy.
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