A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?
Assess the bladder for distention.
Massage the client's fundus.
Prepare to administer a prescribed oxytocic preparation.
Assess client's blood pressure.
The Correct Answer is B
Choice A reason: Assessing the bladder for distention is an important action, but not the first one. The nurse should first check the uterine tone and position, as a boggy or displaced uterus can indicate uterine atony, the most common cause of postpartum hemorrhage.
Choice B reason: Massaging the client's fundus is the first action to take. The nurse should apply firm, circular pressure to the fundus to stimulate uterine contractions and reduce bleeding. The nurse should also monitor the amount and character of lochia.
Choice C reason: Preparing to administer a prescribed oxytocic preparation is a necessary action, but not the first one. The nurse should first attempt to control the bleeding by massaging the fundus and assessing the bladder. If the bleeding persists, the nurse should administer medications such as oxytocin, methylergonovine, or carboprost to enhance uterine contractions.
Choice D reason: Assessing the client's blood pressure is an important action, but not the first one. The nurse should first manage the bleeding by massaging the fundus and preparing to administer medications. The nurse should also monitor the client's vital signs, including blood pressure, pulse, and temperature, for signs of shock or infection
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assessing the bladder for distention is an important action, but not the first one. The nurse should first check the uterine tone and position, as a boggy or displaced uterus can indicate uterine atony, the most common cause of postpartum hemorrhage.
Choice B reason: Massaging the client's fundus is the first action to take. The nurse should apply firm, circular pressure to the fundus to stimulate uterine contractions and reduce bleeding. The nurse should also monitor the amount and character of lochia.
Choice C reason: Preparing to administer a prescribed oxytocic preparation is a necessary action, but not the first one. The nurse should first attempt to control the bleeding by massaging the fundus and assessing the bladder. If the bleeding persists, the nurse should administer medications such as oxytocin, methylergonovine, or carboprost to enhance uterine contractions.
Choice D reason: Assessing the client's blood pressure is an important action, but not the first one. The nurse should first manage the bleeding by massaging the fundus and preparing to administer medications. The nurse should also monitor the client's vital signs, including blood pressure, pulse, and temperature, for signs of shock or infection
Correct Answer is B
Explanation
Choice A reason : Teaching clients' family members how to care for a wound is an educational activity that enhances the family's ability to provide care but does not directly provide feedback on the quality of care given by the staff.
Choice B reason : Tracking the readmission rates of postoperative clients is a direct measure of care quality. High readmission rates can indicate issues with the surgery or the postoperative care, making this a valuable metric for quality assessment.
Choice C reason : Orienting staff to new equipment is important for ensuring safe and effective use, but it does not offer direct feedback on the quality of care. It is more about maintaining competency and safety standards.
Choice D reason : Organizing morale-boosting events is beneficial for staff well-being and can indirectly affect care quality. However, it does not provide immediate feedback on the quality of care provided to clients.
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