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.

Answer and Explanation

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

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Correct Answer is C

Explanation

A. Echinacea has anti-inflammatory properties that can help reduce pain and swelling associated with arthritis. Studies have shown that echinacea can be effective in managing inflammatory conditions like arthritis, making this a likely indicator of its effectiveness.

B. While echinacea may have some calming effects, it is not primarily used to treat sleep disorders. Therefore, improved sleep is not a direct indicator of echinacea's effectiveness.

C. Echinacea is known for its immune-boosting properties, which can aid in wound healing. However, this is not its primary use, and other factors could contribute to wound healing.

D. Echinacea does not have a significant impact on blood pressure. Therefore, a change in blood pressure is not an indicator of its effectiveness.

A. Create diversionary activities for children. B. Help clients gather needed supplies. C. Address the physical needs of clients. D. Explore the feelings the clients are experiencing.

Correct Answer is C

Explanation

Choice A reason: While creating diversionary activities for children is important, it is not the priority. These activities can help alleviate stress and provide a sense of normalcy, but they do not address immediate survival needs.

Choice B reason: Helping clients gather needed supplies is also important, but it is secondary to addressing immediate physical needs. Supplies can be essential for comfort and recovery, but the first concern should be life-sustaining measures.

Choice C reason: Addressing the physical needs of clients is the priority in a disaster situation. This includes providing first aid, securing food and water, and ensuring safety. These actions are crucial for survival and must be addressed before other needs.

Choice D reason: Exploring the feelings the clients are experiencing is a part of psychological first aid and is vital for long-term recovery. However, it is not the immediate priority when compared to physical needs, which are essential for survival.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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