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 C
Explanation
A. "I don't want to lose control of my ability to make decisions." This statement reflects a fear of losing autonomy, which is common among individuals with chronic illnesses. While it indicates anxiety and concern about the future, it does not directly suggest suicidal ideation.
B. "I am afraid of experiencing pain near the end." This response shows a fear of suffering and pain, which is also common in terminal illnesses. Although it indicates distress, it does not necessarily imply a risk for suicide.
C. "I know that everything will be better soon." This statement can be a red flag for suicidal ideation, as it may imply that the person believes death is imminent or that they have a plan to end their suffering. It suggests a sense of hopelessness and a potential desire to escape their current situation.
D. "I am relying more and more on my partner for support." This response indicates a need for increased support and dependency on a partner. While it shows a reliance on others, it does not directly suggest suicidal thoughts or intentions.
Correct Answer is B
Explanation
Choice A reason: This statement is false and discouraging. The caregiver may be eligible for financial assistance for dementia from various sources, such as Medicare, Medicaid, or private insurance.
Choice B reason: This statement is true and supportive. The caregiver may benefit from finding a local support group for caregivers, where they can share their experiences, learn coping strategies, and access resources.
Choice C reason: This statement is unrealistic and harmful. The caregiver should not isolate themselves or their partner from other sources of support. The caregiver may need to delegate some tasks to other family members, friends, or professional caregivers.
Choice D reason: This statement is unreasonable and exhausting. The caregiver should not take over all the activities of daily living (ADLs) for their partner, as this may undermine their partner's autonomy and dignity. The caregiver should encourage their partner to perform ADLs as much as possible, with assistance as needed.
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