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 ["B","D"]
Explanation
Choice A rationale:
This would be incorrect advice. Increasing dietary fiber is commonly recommended during pregnancy to prevent constipation, but it does not address stress incontinence.
Choice B rationale:
This is a correct choice. Kegel exercises are beneficial during pregnancy to strengthen the pelvic floor muscles, which can help manage stress incontinence.
Choice C rationale:
This would be incorrect advice. Restricting daily fluid intake during pregnancy is generally not recommended as it can lead to dehydration and is unlikely to improve stress incontinence.
Choice D rationale:
This is another correct choice. Caffeine is a bladder irritant and can worsen stress incontinence, so reducing caffeine intake can be helpful.
Choice E rationale:
This would be incorrect advice. Regular exercise during pregnancy is generally encouraged unless there are specific medical reasons to avoid it. Avoiding daily exercise is not the appropriate approach to manage stress incontinence.
Correct Answer is A
Explanation
Choice A rationale:
When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.
Choice B rationale:
Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.
Choice C rationale:
Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.
Choice D rationale:
Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.
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