A nurse is caring for a client who delivered an infant vaginally 2 days ago and notes that there are no clots present in the lochia flow, but there is moderate bleeding with bright red blood and small clots present when massaging the fundus which is firm, midline, and at the level of the umbilicus.
Document findings as normal
Massage fundus until it becomes firm
Administer oxytocin
Increase IV fluid rate
The Correct Answer is C
The correct answer is choice C) Administer oxytocin (Pitocin). Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.
The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.
Choice A) Document findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery. Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria. Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots. Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly. Massaging the fundus when it is already firm can cause more bleeding and pain.
Choice D) Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause. Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy. The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The correct answer is choice A, B, C and D. Antibiotics, wound monitoring, wound care and wound culture are all appropriate interventions for a postpartum client who has an episiotomy wound infection.According to Mayo Clinic, an episiotomy wound infection can cause pain, fever, pus and wound breakdown.According to SpringerLink, an episiotomy wound infection is usually caused by a polymicrobial infection of Gram-negative and Gram-positive bacteria.
Therefore, administering antibiotics as prescribed can help treat the infection and prevent complications.
Monitoring wound healing can help detect any signs of worsening infection or dehiscence.
Teaching wound care can help the client prevent further contamination and promote healing.
Culturing the wound if indicated can help identify the causative organisms and guide antibiotic therapy.
Choice E is wrong because applying heat to the wound can increase inflammation and pain.According to NCBI, there is no evidence that heat therapy is beneficial for episiotomy wounds.
Instead, cold therapy may be more effective in reducing swelling and discomfort.
Correct Answer is ["A","C","D","E"]
Explanation
The correct answer is choice A, C, D and E. These are the instructions that the nurse should include in the teaching for a client who had a vaginal delivery with a midline episiotomy.
• Choice A is correct because using a sitz bath three times per day and after each bowel movement can help reduce pain, swelling and infection of the perineum.
• Choice C is correct because applying ice packs to the perineum for the first 24 hours can help reduce inflammation and bleeding.
• Choice D is correct because performing Kegel exercises several times per day can help strengthen the pelvic floor muscles and improve urinary continence.
• Choice E is correct because reporting any increase in redness, swelling or discharge from the episiotomy site can help detect signs of infection or wound breakdown.
• Choice B is wrong because wiping from back to front after voiding or having a bowel movement can increase the risk of infection by introducing bacteria from the anal area to the vaginal area.The correct way to wipe is from front to back.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.