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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Amniocentesis is not a surgical procedure that requires general anesthesia, so the client will not be asleep during the procedure.
Choice B rationale
Fasting is not typically required before an amniocentesis. The procedure involves inserting a thin needle into the amniotic sac to withdraw a small amount of fluid for testing. It does not involve the digestive system, so there is no need for the client to fast.
Choice C rationale
While the client may be in various positions during the procedure, lying on the side is not typically required. The position of the client during the procedure is determined by the location of the baby and the amniotic sac.
Choice D rationale
Emptying the bladder before the procedure can make it easier for the healthcare provider to access the uterus and amniotic sac. Therefore, this statement indicates an understanding of the teaching.
Correct Answer is C
Explanation
Choice A rationale
Applying oxygen at 2 L/min via nasal cannula may be beneficial for a client experiencing hypotension following the administration of epidural anesthesia, but it is not the primary action a nurse should take.
Choice B rationale
Massaging the client’s fundus is not an appropriate action for a nurse to take when a client is hypotensive following the administration of epidural anesthesia.
Choice C rationale
Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
Choice D rationale
Assisting the client to empty their bladder may be beneficial in certain circumstances, but it is not the primary action a nurse should take when a client is hypotensive following the administration of epidural anesthesia.
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