A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?
Prepare to administer a prescribed oxytocic preparation.
Assess the bladder for distention.
Massage the client's fundus.
Assess the client's blood pressure.
The Correct Answer is C
Choice A reason:
Administering a prescribed oxytocic preparation is an important step in managing postpartum hemorrhage, as it helps to contract the uterus and reduce bleeding. However, it is not the first action a nurse should take when a client has saturated a perineal pad within 10 minutes postpartum.
Choice B reason:
Assessing the bladder for distention is also important because a full bladder can impede the contraction of the uterus and lead to increased bleeding. However, this is not the immediate action to take in the event of excessive postpartum bleeding.
Choice C reason:
Massaging the client's fundus is the first action the nurse should take. A boggy uterus, which is soft and not well contracted, can lead to excessive bleeding. Fundal massage stimulates the uterus to contract and can quickly reduce blood loss.
Choice D reason:
Assessing the client's blood pressure is vital to determine the client's hemodynamic status, but it is not the first action to take. The priority is to address the cause of the bleeding and stabilize the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a reason:
Increasing abdominal pain with a nonrelaxed uterus is not typically indicative of placenta previa. This symptom could suggest other complications such as uterine rupture or placental abruption, which are serious conditions requiring immediate medical attention.
Choice b reason:
Abdominal pain with scant red vaginal bleeding is also not a classic sign of placenta previa. While vaginal bleeding can occur in placenta previa, it is usually not associated with abdominal pain. Pain accompanied by bleeding is more suggestive of other obstetric emergencies.
Choice c reason:
Painless red vaginal bleeding is a hallmark sign of placenta previa. In placenta previa, the placenta covers the cervical os either partially or completely, leading to bleeding when the lower part of the uterus stretches and thins as part of the preparation for labor. This bleeding is typically sudden and painless and can range from light to heavy.
Choice d reason:
Intermittent abdominal pain following the passage of bloody mucus is not characteristic of placenta previa. This symptom could be associated with the normal process of losing the mucus plug as labor approaches or could indicate other conditions but is not specific to placenta previa.
Correct Answer is B
Explanation
Choice A reason:
While burping can be a sign that a baby is feeding, it is not a reliable indicator of whether the baby is getting enough breast milk. Burping is a way to release air that babies swallow during feeding, which can help prevent discomfort and gas. However, it does not correlate directly with the amount of milk intake.
Choice B reason:
The number of wet diapers is a direct indicator of a baby's hydration status and, by extension, how much breast milk they are receiving. A newborn who is getting enough milk will typically have 6 to 8 wet diapers per day after the first few days of life. This shows that the baby is well-hydrated and is receiving sufficient milk.
Choice C reason:
Sleep patterns in newborns can vary widely, and sleeping for at least 6 hours between feedings is not typical for a 2-day-old baby. Newborns usually need to feed every 2 to 3 hours, and long stretches of sleep without feeding may indicate that the baby is not getting enough milk and does not have the energy to wake and feed.
Choice D reason:
A wake cycle of 30 to 60 minutes after feeding can be normal for some babies, but it is not a measure of whether they are getting enough milk. The wake cycle can be influenced by many factors, including the baby's overall health, comfort, and environment.
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