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 D
Explanation
Choice A rationale:
The normal WBC count during pregnancy can vary, but a count of 11,000/mm³ is within an acceptable range. During pregnancy, the WBC count can be slightly elevated due to physiological changes in the body to support the growing fetus.
Choice B rationale:
The normal hemoglobin level during pregnancy is generally around 11 to 12.5 g/dL. Therefore, a hemoglobin level of 11.2 g/dL falls within the normal range, and the nurse does not need to report this finding.
Choice C rationale:
The normal hematocrit (Hct) during pregnancy can vary, but a level of 34% is within the acceptable range. Hct levels can be lower during pregnancy due to increased plasma volume, leading to a mild physiological anemia of pregnancy.
Choice D rationale:
The normal platelet count during pregnancy is typically around 150,000 to 400,000/mm³. With a platelet count of 140,000/mm³, this is slightly below the lower end of the normal range. Thrombocytopenia during pregnancy can increase the risk of bleeding, both during childbirth and postpartum, so the nurse should report this finding to the provider for further evaluation and management.
Correct Answer is A
Explanation
Choice A rationale:
The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.
Choice B rationale:
Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.
Choice C rationale:
Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.
Choice D rationale:
Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.
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