A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
Elevate the client's legs to a 30° angle.
Insert an indwelling urinary catheter.
Massage the client's fundus.
Initiate an infusion of oxytocin.
The Correct Answer is C
Choice C rationale:
The nurse should first massage the client's fundus to address the excessive vaginal bleeding. Massaging the fundus helps the uterus contract and prevents further bleeding. Excessive postpartum bleeding may indicate uterine atony, which is a leading cause of postpartum hemorrhage. The nurse should apply gentle pressure to the fundus to promote uterine contractions and reduce bleeding.
Choice A rationale:
Elevating the client's legs to a 30° angle (Trendelenburg position) is not the priority action in this situation. Fundal massage takes precedence because it directly addresses the cause of the excessive bleeding. While Trendelenburg position might be used in some situations to increase blood flow to vital organs, it is not the first-line intervention for postpartum bleeding.
Choice B rationale:
Inserting an indwelling urinary catheter is not the priority action for excessive vaginal bleeding. While monitoring urine output is essential, the immediate concern is controlling the bleeding by massaging the fundus.
Choice D rationale:
Initiating an infusion of oxytocin may be indicated if fundal massage alone is insufficient to control bleeding. However, massaging the fundus should be the first action taken to promote uterine contractions. Oxytocin can be administered afterward, if needed, under the direction of a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Vitamin E is important for overall health but does not need to be specifically increased during pregnancy.
B. Vitamin D supports calcium absorption, but routine intake is generally sufficient unless a deficiency exists.
C. Fiber intake should be increased during pregnancy to help prevent constipation, which is a common issue due to hormonal changes and slowed gastrointestinal motility.
D. Calcium intake is important, but for many clients, standard dietary recommendations are adequate unless otherwise prescribed.
Correct Answer is C
Explanation
The correct answer is choice C: "I will tip the nipple so air is present as my baby sucks.”
Choice A rationale:
The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.
Choice B rationale:
The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.
Choice C rationale:
Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.
Choice D Rationale:
Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.
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