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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:
Covering the cord with a sterile, moist saline dressing can help to maintain the cord's viability by preventing drying and possible infection. However, this action does not address the immediate concern of relieving pressure on the cord to restore fetal circulation.

Choice B reason:
Placing the client in the knee-chest position is the most immediate and critical action to take. This position helps to relieve pressure on the prolapsed cord, which is vital to prevent compression of the cord and maintain blood flow to the fetus. It is a recommended emergency intervention for umbilical cord prolapse.

Choice C reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is a measure that may be taken by a healthcare provider in the event of a cord prolapse. However, it is not the first action to be performed. The initial step is to change the mother's position to relieve pressure on the cord.

Choice D reason:
Preparing the client for an immediate birth is necessary because umbilical cord prolapse is an obstetric emergency that requires prompt delivery, often by cesarean section, to prevent fetal hypoxia. However, the very first action is to relieve pressure on the cord to restore fetal oxygenation while preparations for delivery are made.

A. Wash the perineal area using a squeeze bottle of warm water after each voiding. B. Apply ice packs to the perineal area several times daily. C. Blot the perineal area dry after cleansing. D. Clean the perineal area from front to back. E. Wash hands before and after voiding.

Correct Answer is ["A","C","D","E"]

Explanation

Choice a reason:
Washing the perineal area using a squeeze bottle of warm water after each voiding is a recommended practice to reduce the risk of infection. This method gently cleanses without causing irritation and ensures that any bacteria are washed away, which is particularly important after a vaginal delivery when the perineal tissue may be more susceptible to infection.

Choice b reason:
Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, but it is not directly related to reducing the risk of infection. Ice packs should be used as part of pain management and swelling reduction rather than for hygiene purposes.

Choice c reason:
Blotting the perineal area dry after cleansing is important to maintain the integrity of the skin and prevent moisture buildup, which can create an environment conducive to bacterial growth. Patting the area dry gently can help prevent irritation and reduce the risk of infection.

Choice d reason:
Cleaning the perineal area from front to back is a critical practice to prevent the spread of bacteria from the anal area to the vagina and urethra, which can cause urinary tract infections. This technique is especially important postpartum when the perineal area is healing.

Choice e reason:
Performing hand hygiene before and after voiding is a fundamental practice to prevent the introduction of pathogens to the perineal area and reduce the risk of infection. Proper handwashing can significantly decrease the likelihood of perineal infections by ensuring that the hands are clean when they come into contact with sensitive areas.

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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?

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Correct Answer is B

Explanation

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