A nurse is caring for a client who is 1 hour postpartum following a vaginal birth.
The client has saturated a perineal pad within 10 minutes.
Which of the following actions should the nurse take first?
Prepare to administer a prescribed oxytocic preparation.
Assess the client's blood pressure.
Assess the bladder for distention.
Massage the client's fundus.
The Correct Answer is D
Choice A rationale
Preparing to administer a prescribed oxytocic preparation is a possible intervention for postpartum hemorrhage, but the immediate first step should be to assess the uterus, the most common source of early postpartum bleeding.
Choice B rationale
Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.
Choice C rationale
Assessing the bladder for distention is important as a full bladder can displace the uterus and interfere with its contraction, potentially contributing to bleeding. However, directly addressing the uterine tone is the immediate first step.
Choice D rationale
Massaging the client's fundus is the priority action because uterine atony, a soft and non-contracted uterus, is the most frequent cause of early postpartum hemorrhage. Stimulating the uterus to contract by massage helps to compress the blood vessels at the placental site and decrease bleeding. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A firm fundus displaced to the right and above the umbilicus often indicates a full bladder. The bladder, when distended, can push the uterus out of its midline position and interfere with its ability to contract effectively, potentially leading to increased bleeding. Having the client void will relieve the pressure on the uterus, allowing it to return to its midline position and remain firm.
Choice B rationale
Starting a pad count is a useful way to quantify the amount of lochia, but it does not address the immediate issue of the displaced fundus and potential bladder distention. It would be a subsequent step to monitor the bleeding after addressing the fundal position.
Choice C rationale
While fundal massage is appropriate for a soft or boggy uterus, the assessment indicates the fundus is already firm. Massaging a firm uterus is not the priority and will not address the displacement caused by a likely full bladder.
Choice D rationale
Notifying the healthcare provider is necessary if the fundus remains displaced and elevated after the client voids, as this could indicate other complications. However, the initial action should be to address the most likely cause, which is bladder distention.
Correct Answer is A
Explanation
Choice A rationale
True labor is characterized by progressive cervical changes, including effacement (thinning) and dilation (opening) of the cervix. These changes are the most definitive signs that a woman is in true labor, as contractions can sometimes be Braxton Hicks contractions, which do not cause cervical change.
Choice B rationale
The station of the presenting part (how far down the baby's head is in the pelvis) can change during true labor as the baby descends. However, a single assessment of station does not definitively indicate true labor, as the baby may have been in a lower position prior to the onset of labor. Cervical changes are a more reliable indicator.
Choice C rationale
Rupture of the membranes (water breaking) can occur before or during true labor, but it is not always the first sign of labor. Some women experience contractions for a period before their membranes rupture, and some may not have their membranes rupture until late in labor or require artificial rupture. Therefore, it is not the most definitive sign of true labor.
Choice D rationale
A pattern of regular contractions that increase in frequency, duration, and intensity is a strong indication of true labor. However, some women may experience irregular contractions (Braxton Hicks) that can be mistaken for early labor. The key differentiator is whether these contractions are causing cervical change, making cervical assessment the most definitive sign.
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