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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason:
Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Choice B reason:
Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.
Choice C reason:
Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.
Choice D reason:
This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should discontinue the oxytocin infusion if the client's contraction frequency is every 3 minutes. Frequent contractions may lead to uterine hyperstimulation, which can reduce fetal blood flow and oxygenation, potentially causing fetal distress. Normal contraction frequency during labor is typically every 2 to 5 minutes.
Choice B rationale:
Contraction duration of 100 seconds is not an indication to discontinue the oxytocin infusion. The duration of contractions can vary during labor, and 100 seconds is within the normal range of contraction duration, which is usually 45 to 90 seconds.
Choice C rationale:
Fetal heart rate with moderate variability is not an indication to discontinue the oxytocin infusion. Moderate variability in fetal heart rate is a reassuring sign, indicating a healthy fetal response to labor. It shows that the fetus is tolerating the contractions well and is not experiencing fetal distress.
Choice D rationale:
A fetal heart rate of 118/min is not an indication to discontinue the oxytocin infusion. The normal fetal heart rate range is typically between 110 to 160 beats per minute, and a heart rate of 118/min falls within this normal range. However, if the fetal heart rate deviates significantly from the normal range or shows signs of distress, further assessment and intervention are required.
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