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
Pale, translucent skin is not typically a characteristic of a postterm newborn. Postterm newborns often have dry, peeling, loose skin.
Choice B rationale
Large deposits of subcutaneous fat are not usually seen in postterm newborns. In fact, these babies may appear abnormally thin, especially if the function of the placenta was severely reduced near the end of the pregnancy.
Choice C rationale
Nails extending over the tips of the fingers is indeed a common characteristic of postterm newborns. This is because the baby has had more time to grow in the womb.
Choice D rationale
A thin covering of fine hair on the shoulders and back is not typically seen in postterm newborns. This characteristic is more commonly associated with preterm babies.
Correct Answer is C
Explanation
Choice A rationale
A protective environment is not typically required for clients with MRSA141516. This type of precaution is usually used for clients who are severely immunocompromised and need to be protected from any potential sources of infection.
Choice B rationale
Droplet precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis.
Choice C rationale
Contact precautions are recommended for clients with MRSA141516. This involves using personal protective equipment and limiting patient movement outside of the room.
Choice D rationale
Airborne precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through tiny airborne droplets, such as tuberculosis or chickenpox.
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.