A nurse is caring for a client who delivered by cesarean birth 6 hours ago.
The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?
Administer 500 mL lactated Ringer’s IV bolus.
Evaluate urinary output.
Apply an ice pack to the incision site.
Replace the surgical dressing.
The Correct Answer is A
Choice A rationale
If a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage after a cesarean birth, administering a 500 mL lactated Ringer’s IV bolus can help increase the client’s circulating volume and support her hemodynamic stability. This is often the first step in managing postpartum hemorrhage.
Choice B rationale
While evaluating urinary output is an important aspect of postoperative care, it would not directly address the issue of ongoing vaginal bleeding.
Choice C rationale
Applying an ice pack to the incision site can help reduce swelling and provide some pain relief, but it would not address the issue of vaginal bleeding.
Choice D rationale
Replacing the surgical dressing is part of routine postoperative care, but it would not directly address the issue of ongoing vaginal bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Asking when the client last ate meat is not relevant for assessing dietary intake in a client who adheres to a vegan diet. Vegans do not consume meat or any other animal products.
Choice B rationale
While vitamin C is an important nutrient, it is not typically a concern for vegans as it is abundant in fruits and vegetables. Therefore, asking about vitamin C supplementation may not provide the most useful information about the client’s dietary intake.
Choice C rationale
Protein intake is a key concern for individuals following a vegan diet, as many sources of protein are animal-based. Vegans can get protein from foods like lentils, chickpeas, beans, tofu, and nuts. Therefore, asking about daily protein intake can provide valuable information about the client’s dietary habits and nutritional status.
Choice D rationale
Shellfish are not part of a vegan diet, so asking if the client has considered eating shellfish would not be relevant or appropriate.
Correct Answer is A
Explanation
The correct answer is choice a. Check the client’s serum medication level.
Choice A rationale:
Checking the client’s serum medication level is the most direct and objective method to evaluate medication adherence. It provides a quantifiable measure of the digoxin level in the blood, indicating whether the client is taking the medication as prescribed.
Choice B rationale:
Determining the client’s apical pulse rate is important for monitoring the effects of digoxin, as it can affect heart rate. However, it does not directly measure medication adherence.
Choice C rationale:
Asking the client if they are taking the medication as prescribed relies on self-reporting, which can be inaccurate due to forgetfulness or intentional non-disclosure.
Choice D rationale:
Assessing the client’s kidney function is important for dosing and monitoring potential side effects of digoxin, but it does not directly evaluate medication adherence.
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