A nurse is caring for a client who had a vaginal delivery 2 hours ago.
Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Observe the lochia during palpation of the fundus.
Massage a firm fundus.
Determine whether the fundus is midline.
Document fundal height.
Administer methylergonovine maleate.
Correct Answer : A,C,E
Step 1: The nurse should observe the lochia during palpation of the fundus. This can help assess the amount and type of vaginal discharge after childbirth.
Step 2: The nurse should not massage a firm fundus. If the uterus is firm, it means it is contracting well to control bleeding.
Step 3: The nurse should determine whether the fundus is midline. A uterus that is not midline may indicate a full bladder, which can interfere with uterine contraction and lead to increased bleeding.
Step 4: Documenting fundal height is not typically done postpartum. Instead, the nurse assesses whether the fundus is firm and midline.
Step 5: The nurse should administer methylergonovine maleate if the uterus is boggy. This medication helps the uterus contract to control bleeding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Intermittent abdominal pain following passage of bloody mucus is more commonly associated with labor or conditions like bloody show but not specifically indicative of placenta previa.
Choice B rationale
Increasing abdominal pain with a non-relaxed uterus could be a sign of conditions such as uterine rupture or contractions, but it is not a typical sign of placenta previa. In placenta previa, the uterus is typically soft and non-tender.
Choice C rationale
Abdominal pain with scant red vaginal bleeding could be indicative of several conditions, including early labor or placental abruption, but it is not a typical sign of placenta previa. Placenta previa is usually characterized by painless bleeding.
Choice D rationale
Painless red vaginal bleeding is a classic sign of placenta previa. This occurs because the placenta, which is implanted low in the uterus, near or over the cervical os, begins to separate as the cervix effaces and dilates, leading to bleeding.
Correct Answer is ["A","C"]
Explanation
A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
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