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
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Related Questions
Correct Answer is D
No explanation
Correct Answer is B
Explanation
A. The client is experiencing postpartum depression. A prescription of antidepressants is important but should come after fully assessing the client's mental state
B. Asking the client if she has considered harming her newborn is important in further assessments to establish the mothers as it is a common feature of postpartum depression.
C. While reinforcing education on postpartum and newborn care is important for overall maternal and infant well-being, it may not directly address the client's current mental health concerns.
D. Exploring options on how to help the client is key but this should comer after a thorough examination has occurred.
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