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: The client’s insurance provides coverage for palliative care
This option is incorrect. While insurance coverage for palliative care is important, it is not a qualifying criterion for hospice care. Hospice care eligibility is primarily based on the patient’s medical condition and prognosis, not on insurance coverage.
Choice B: The client has declined additional life prolonging treatments
This option is correct. One of the key criteria for hospice care is that the patient must choose palliative care (comfort care) over curative treatments. This means the patient has decided to stop treatments aimed at prolonging life and instead focus on quality of life and symptom management.
Choice C: The client requires inpatient care due to lack of a caregiver
This option is incorrect. While the need for inpatient care can be a factor in the type of hospice services provided, it is not a criterion for qualifying for hospice care. Hospice care can be provided in various settings, including the patient’s home, regardless of caregiver availability.
Choice D: The client has documentation stating he has less than 12 months to live
This option is incorrect. The standard criterion for hospice care is a prognosis of six months or less to live if the disease follows its usual course. Documentation stating a life expectancy of less than 12 months does not meet the hospice eligibility requirement.
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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