A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather 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°.
Administer oxytocin by continuous IV infusion.
Insert an indwelling urinary catheter.
Massage the client's fundus to promote contractions.
The Correct Answer is D
A. Tilting the client onto her right side with her legs elevated does not directly address the underlying cause of postpartum hemorrhage.
B. Oxytocin is a uterotonic medication commonly used to help control and prevent PPH by promoting uterine contractions, which can help to compress blood vessels and reduce bleeding. However, it is not the priority action.
C. Inserting an indwelling urinary catheter may be necessary to monitor urine output and empty the bladder but is not a priority.
D. Massaging the client's fundus to promote contractions is a standard intervention and initial action for managing PPH
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Early decelerations are usually benign and are associated with head compression during contractions.
B. Accelerations are increases in the fetal heart rate above the baseline. They are typically reassuring and indicate fetal well-being.
C. Late decelerations are concerning patterns in fetal heart rate monitoring. They can indicate poor oxygenation of the fetus and may be associated with conditions such as maternal hypotension, placental insufficiency, or other factors compromising blood flow to the fetus.
D. Variable decelerations are abrupt decreases in fetal heart rate that vary in timing, duration, and depth. They are often associated with umbilical cord compression, such as when the cord is being compressed or squeezed during contractions.
Correct Answer is C
Explanation
Allowing the baby to drain one breast at each feeding helps ensure effective milk removal, which can alleviate breast engorgement. Emptying the breast thoroughly promotes milk flow and prevents milk stasis, which contributes to engorgement.
A Cold compresses provide temporary relief from discomfort but does not address the underlying cause of engorgement.
B Drinking herbal tea, may have limited evidence supporting its efficacy in reducing engorgement. While hydration is important for breastfeeding, relying solely on herbal tea may not be as effective as other strategies.
D Feeding the baby every 2 hours, is important for maintaining milk supply and preventing engorgement. However, it's essential to ensure the breast is fully drained at each feeding, regardless of the time interval between feedings.
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