A nurse is caring for a client who is 2 hours postpartum.
The nurse notes that the client soaked a perineal pad in 10 minutes, the client’s skin color is ashen, and she states she feels weak and light-headed.
After applying oxygen via a non-rebreather face mask at 10 L/min, which of the following actions should the nurse take next?
Tilt the client onto her right side with her legs elevated to at least 30 degrees.
Administer oxytocin by continuous IV infusion.
Insert an indwelling urinary catheter.
Massage the client’s fundus to promote contractions.
The Correct Answer is D
Choice A rationale
Tilt the client onto her right side with her legs elevated to at least 30 degrees. This action is not the most immediate step to take. While it can help improve venous return and thus cardiac output, it does not directly address the issue of postpartum hemorrhage.
Choice B rationale
Administer oxytocin by continuous IV infusion. Oxytocin is a medication that can stimulate uterine contractions and help control postpartum bleeding. However, it should be administered after the nurse has assessed the uterus and determined that it is not contracting effectively on its own.
Choice C rationale
Insert an indwelling urinary catheter. While a full bladder can inhibit effective uterine contractions and contribute to bleeding, inserting a catheter is not the first step in managing a postpartum hemorrhage.
Choice D rationale
Massage the client’s fundus to promote contractions. This is the correct answer. Fundal massage stimulates the uterus to contract, which can help control postpartum bleeding. It is a first-line intervention for a boggy uterus and postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The largest fetal diameter passing through the pelvic outlet is not what is indicated by the presenting part being at 0 station. This would be more indicative of a positive station, such as
+31.
Choice B rationale
The position of the fetal head, such as left occiput posterior, is not determined by the station of the presenting part. The station refers to the level of the presenting part in relation to the mother’s ischial spines.
Choice C rationale
The palpability of the posterior fontanel is not related to the station of the presenting part. The fontanels are soft spots on the baby’s head which allow for compression during birth and brain growth after birth.
Choice D rationale
This is the correct interpretation of the clinical finding. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines.
Correct Answer is B
Explanation
Choice A rationale
While it is true that preterm newborns have a smaller body surface area than full-term newborns, this is not the primary reason for using an incubator. A smaller body surface area can contribute to heat loss, but the main issue is the lack of adequate temperature control mechanisms.
Choice B rationale
Preterm newborns lack the adequate temperature control mechanisms that full-term newborns have. They have less subcutaneous fat to insulate them and a higher surface area to volume ratio, which increases heat loss. They also lack the ability to shiver to generate heat.
Therefore, an incubator is used to maintain a neutral thermal environment.
Choice C rationale
The heat in the incubator does not rapidly dry the sweat of preterm newborns. In fact, preterm newborns do not sweat as efficiently as full-term newborns or adults, so they are less likely to lose heat through sweating.
Choice D rationale
The statement that the added brown fat layer in preterm newborn reduces his ability to generate heat is incorrect. In fact, preterm newborns have less brown fat than full-term newborns. Brown fat is a type of fat that generates heat when metabolized, and it is an important source of heat for newborns.
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