A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?
Assist the client to a sitz bath.
Assess the client's uterine tone.
Encourage the client to breastfeed.
Apply an ice pack to the client's perineum.
The Correct Answer is B
Choice A rationale:
Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.
Choice B rationale:
Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.
Choice C rationale:
Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.
Choice D rationale:
Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.
Choice B rationale:
This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.
Choice C rationale:
Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.
Choice D rationale:
Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.
Correct Answer is D
Explanation
Choice A rationale:
Periodic tingling of fingers is a common symptom during pregnancy and is often related to hormonal changes and increased fluid retention. While it can be uncomfortable, it is not necessarily an indication of a potential prenatal complication.
Choice B rationale:
Absence of clonus is not an abnormal finding during pregnancy. Clonus is a series of involuntary muscle contractions and relaxations and is generally not expected during a routine assessment.
Choice C rationale:
Leg cramps are a common complaint during pregnancy and are usually caused by changes in calcium and magnesium levels. While they can be uncomfortable, they are not typically considered an indication of a potential prenatal complication.
Choice D rationale:
Blurred vision can be an indication of preeclampsia, a serious condition that can occur during pregnancy. Preeclampsia is characterized by high blood pressure and damage to organs, often affecting the eyes, kidneys, and liver. It is crucial for the nurse to recognize this symptom and promptly inform the healthcare provider for further evaluation and management.
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