A nurse is caring for a client who is 36 hours postpartum and has a distended bladder.The client reports saturating four perineal pads in the past hour.
Which of the following actions should the nurse take? (Select all that apply.)
Palpate the fundus for location and tone.
Check the client's blood pressure and pulse.
Look under the client's buttocks.
Administer intravenous infusion of 0.9
Place the client in reverse Trendelenburg position.
Correct Answer : A,B,C
Choice A rationale
Palpating the fundus is crucial because a full bladder displaces the uterus superiorly and laterally, impeding its ability to contract effectively (uterine atony). Uterine atony is the primary cause of early postpartum hemorrhage (PPH). Assessing the fundal location and tone provides direct evidence of uterine involution progress and identifies potential PPH risk; a soft, boggy fundus requires immediate intervention to prevent excessive blood loss.
Choice B rationale
Assessing the client's blood pressure (BP) and pulse is an essential rapid assessment for signs of hypovolemic shock, which can result from excessive blood loss indicated by saturating four perineal pads in one hour (suggestive of PPH). A decrease in BP (hypotension) and an increase in pulse rate (tachycardia) are classic compensatory mechanisms and late indicators of significant volume depletion, demanding prompt resuscitation and definitive hemorrhage control. Normal adult BP is typically less than 120/80 mmHg; normal pulse is 60-100 beats/minute.
Choice C rationale
Inspecting under the client's buttocks is vital because blood can pool there without being immediately visible on the perineal pad, leading to an underestimation of total blood loss. Postpartum hemorrhage is defined as blood loss greater than 500 mL following a vaginal birth or greater than 1000 mL after a Cesarean birth. Hidden blood accumulation contributes to delayed recognition of the severity of PPH, which can rapidly progress to instability.
Choice D rationale
Administering a non-additive intravenous infusion (like 0.9.
Choice E rationale
Placing the client in the reverse Trendelenburg position involves lowering the head and raising the foot of the bed, which increases venous pooling in the lower extremities and may slightly lower cerebral perfusion. This position is generally contraindicated in a client with suspected or active postpartum hemorrhage (PPH) or hypovolemic shock, as it can worsen hypotension and compromise circulation to vital organs. The Trendelenburg position (head lower than feet) is sometimes used for shock, but the reverse position is inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Step 1 is: Determine the ordered daily dosage. The order is 500 mg po q hours, which is four doses per day (24 hours÷ 6 hours = 4). 500 mg/dose× 4 doses/24 h = 2000 mg/24 h.
Step 2 is: Compare the ordered daily dosage (2000 mg/24 h) to the calculated safe daily dosage range (500 mg/24 h to 1000 mg/24 h from. 2000 mg/24 h is greater than 1000 mg/24 h. Based on the calculated safe range, the dose is 𝐮𝐧𝐬𝐚𝐟𝐞.
Correct Answer is B
Explanation
Choice A rationale
Crying is an expressive behavior and communication method for the newborn, signaling needs like hunger or discomfort, but it is not classified as a primitive or protective reflex. Primitive reflexes are involuntary, automatic motor responses integrated by the central nervous system that typically disappear as the cerebral cortex matures.
Choice B rationale
Grasping, specifically the palmar grasp reflex, is an involuntary, primitive newborn reflex where stroking the palm causes the infant to close the fingers in a tight grip. This is an example of an automatic, protective motor response mediated by the central nervous system that is present at birth and typically fades around three to six months of age.
Choice C rationale
Talking is a complex, acquired developmental milestone involving sophisticated cognitive, motor, and linguistic skills. It requires extensive learning and maturation of the cerebral cortex, distinguishing it as a learned behavior, not an innate, involuntary, and transient newborn reflex present from birth.
Choice D rationale
Walking, or ambulation, is a major gross motor developmental milestone achieved typically between 9 and 18 months of age, requiring significant muscle strength, coordination, and cerebral maturation. While the stepping (or walking) reflex is present at birth, voluntary walking is a learned skill, not a transient newborn reflex.
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