A nurse is caring for a client who is 4 hr postpartum. The nurse notes four saturated perineal pads in the past hour. Which of the following actions should the nurse take first?
Administer misoprostol.
Increase maintenance IV fluid.
Perform perineal hygiene.
Perform fundal assessment and massage.
The Correct Answer is D
A. administering misoprostol, may be indicated in postpartum care, but it is not the first priority in this situation. The immediate concern is excessive bleeding, which should be addressed first.
B. increasing maintenance IV fluid, is not the first action to take. While fluid management is important, it is not the priority when the client is experiencing excessive postpartum bleeding.
C. performing perineal hygiene, is important for overall hygiene, but it is not the first action to take when the client is experiencing excessive bleeding. Controlling bleeding takes precedence.
D. performing fundal assessment and massage, is the first priority. This helps assess for uterine atony (failure of the uterus to contract), a common cause of postpartum hemorrhage. Massage can stimulate uterine contractions and help control bleeding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A weight gain of 16.4 to 20.5 kg (36 to 45 lb) is excessive for a client with a pre-pregnancy BMI of 21, which falls within the normal range. Such weight gain is more appropriate for an underweight client.
B. A weight gain of 5 to 7.7 kg (11 to 17 lb) is inadequate for a client with a normal pre-pregnancy BMI. This range is suitable for an overweight or obese client.
C. A pre-pregnancy BMI of 21 falls within the normal range (18.5–24.9), and the recommended weight gain for clients in this category is 11.4 to 15.9 kg (25 to 35 lb). This range supports healthy fetal growth and reduces the risk of complications.
D. A weight gain of 8.2 to 10.9 kg (18 to 24 lb) is slightly below the recommended range for a client with a normal BMI and may not adequately support fetal development. This range is more appropriate for overweight individuals.
Correct Answer is C
Explanation
A. Placing the client in a side-lying position may be a comfort measure, but it may not address the afterpains directly.
B. Applying a cool compress may provide some relief, but it may not be as effective as administering medication for pain relief.
C. Administering ibuprofen or other appropriate pain medication can help relieve afterpains, which are caused by uterine contractions after childbirth.
D. Encouraging Kegel exercises is not relevant to relieving afterpains. Kegel exercises are beneficial for pelvic floor muscle strength but do not directly address afterpains.
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