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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Reporting the situation to the provider and preparing for induction of labor may be premature without first attempting to stimulate fetal movement. Nonstress tests can have periods of no observed movement without indicating immediate distress or the need for labor induction.
Choice B reason:
Turning the client onto her left side can improve uteroplacental blood flow, which might indirectly stimulate fetal movement. However, this action alone may not be sufficient to prompt fetal activity during a nonstress test.
Choice C reason:
Encouraging the client to walk around could potentially stimulate fetal movement, but it is not the standard initial response during a nonstress test. Walking without monitoring may also miss capturing any potential movements that occur during that time.
Choice D reason:
Offering the client a snack of orange juice and crackers is a common and non-invasive method to encourage fetal movement. The natural sugars in the orange juice can increase the baby's blood glucose levels, potentially leading to increased activity that can be observed on the nonstress test.
Correct Answer is D
Explanation
The correct answer is choice D: Document the findings and continue to monitor the client.
Rationale:
Choice A: While encouraging the client to empty her bladder is important to help with uterine contraction, it's not the priority in this situation. The client's fundus is firm and midline, indicating good uterine contraction.
Choice B: Increasing the frequency of fundal massage is not necessary when the fundus is firm and midline. Excessive fundal massage can lead to uterine fatigue and decreased contractility.
Choice C: Notifying the client's provider is not necessary for a moderate amount of lochia rubra and small clots in the early postpartum period. This is a normal finding.
Choice D: Documenting the findings and continuing to monitor the client is the correct action. The nurse should document the amount, color, and consistency of lochia, as well as the fundus assessment. The client should be monitored closely for any signs of excessive bleeding or uterine atony.
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