A nurse is caring for a client who has postpartum hemorrhage and is receiving IV fluids and blood products.

Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Monitor intake and output

Elevate the head of the bed

Apply oxygen via nasal cannula

Insert a nasogastric tube E

Administer pain medication as needed

Answer and Explanation

Correct Answer : A,B,C

The correct answer is choice A, B and C. The nurse should monitor intake and output to assess the client’s fluid status and blood loss.

The nurse should elevate the head of the bed to reduce the risk of hypovolemic shock and improve tissue perfusion.

The nurse should apply oxygen via nasal cannula to increase oxygen delivery to the vital organs and prevent hypoxia.

Choice D is wrong because inserting a nasogastric tube is not indicated for a client who has postpartum hemorrhage.

A nasogastric tube is used to decompress the stomach or administer medications or feedings in some conditions.

Choice E is wrong because administering pain medication as needed is not a priority intervention for a client who has postpartum hemorrhage.

Pain medication can mask the signs of shock and lower the blood pressure further.

The nurse should focus on restoring the blood volume and preventing complications.

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Correct Answer is B

Explanation

The client has a firm and midline uterus at the umbilicus.This indicates that the interventions for postpartum hemorrhage due to retained placental fragments are successful because the uterus has contracted and expelled the fragments, and there is no excessive bleeding.

Choice A is wrong because minimal cramping and discomfort are not specific signs of successful interventions for postpartum hemorrhage.

They may also occur in normal postpartum recovery.

Choice C is wrong because passing small clots with moderate lochia rubra may indicate that there are still some retained placental fragments or that the uterus is not contracting adequately.

Choice D is wrong because a pulse rate of 100 beats/min and a blood pressure of 110/70 mm Hg are not normal ranges for an adult.A pulse rate of 60 to 100 beats/min and a blood pressure of less than 120/80 mm Hg are considered normal.A high pulse rate and a low blood pressure may indicate hypovolemia or shock due to blood loss.

A. Administering oxytocin B. Administering magnesium sulfate C. Administering heparin D. Administering insulin

Correct Answer is A

Explanation

Oxytocin is a uterotonic medication that stimulates uterine contractions and reduces bleeding.It is the most effective intervention for preventing and treating postpartum hemorrhage caused by uterine atony.

Uterine massage can also help to improve uterine tone and expel clots.

Choice B) Administering magnesium sulfate is wrong because magnesium sulfate is used to prevent seizures in patients with preeclampsia or eclampsia, not to control bleeding.

Choice C) Administering heparin is wrong because heparin is an anticoagulant that prevents blood clotting.

It is used to treat or prevent thromboembolic disorders, not to stop bleeding.

Choice D) Administering insulin is wrong because insulin is used to lower blood glucose levels in patients with diabetes mellitus, not to manage hemorrhage.

Normal blood loss after vaginal delivery is less than 500 mL and after cesarean delivery is less than 1000 mL.

Postpartum hemorrhage is defined as blood loss of at least 100

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A nurse is caring for a client who has postpartum hemorrhage and is receiving IV fluids and blood products. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating the effectiveness of interventions for a client who has postpartum hemorrhage due to retained placental fragments. Which of the following outcomes indicates that the interventions are successful?

Correct Answer is B

Explanation

Which of the following is a nursing intervention for postpartum hemorrhage?

Correct Answer is A

Explanation

A nurse is caring for a client who has just delivered her baby and is at risk for postpartum hemorrhage (PPH). Which intervention should be included in this client’s plan of care?

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A nurse is caring for a client who has postpartum hemorrhage and is receiving IV fluids and blood products.

Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)