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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Applying cold compresses 20 minutes before each feeding may not be the most effective way to manage breast engorgement. Cold compresses can help to reduce swelling and relieve pain, but they do not address the underlying cause of engorgement, which is the accumulation of milk in the breasts.

Choice B rationale

Drinking herbal tea to reduce engorgement is not a proven method. While some herbs are believed to have galactagogue properties (increase milk production), they do not directly address breast engorgement. Furthermore, the safety and efficacy of many herbal remedies are not well-studied, and some may have side effects.

Choice C rationale

Letting the baby drain one breast at each feeding can help to alleviate engorgement, but it may not be sufficient if the feedings are spaced too far apart. The breasts continue to produce milk between feedings, and if the milk is not removed, engorgement can occur.

Choice D rationale

Feeding the baby every 2 hours can help to manage breast engorgement. Regular feedings help to ensure that the milk is being removed from the breasts, preventing the buildup that leads to engorgement.

A. A client at 28 weeks of gestation reporting painless vaginal bleeding. B. A client who has missed a period and is experiencing vaginal spotting. C. A client at 14 weeks of gestation reporting nausea and vomiting. D. A client at 38 weeks of gestation reporting a cough and fever.

Correct Answer is A

Explanation

Choice A rationale

Painless vaginal bleeding at 28 weeks of gestation can be a sign of placenta previa or placental abruption, both of which are serious conditions that require immediate attention.

Choice B rationale

While vaginal spotting after a missed period could indicate early pregnancy, it is not as immediately concerning as painless vaginal bleeding in the third trimester.

Choice C rationale

Nausea and vomiting at 14 weeks of gestation are common symptoms of early pregnancy and, while uncomfortable, are not usually a medical emergency.

Choice D rationale

A cough and fever at 38 weeks of gestation could indicate an infection, which should be evaluated. However, it is not as immediately concerning as painless vaginal bleeding in the third trimester.

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Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse prioritize?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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