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 B
Explanation
A. Nifedipine does not directly affect platelet count.
B. Nifedipine is a calcium channel blocker used to lower blood pressure. Monitoring for a decrease in blood pressure is essential.
C. Nifedipine does not typically cause a significant decrease in fetal heart rate (FHR).
D. While nifedipine may impact urinary output indirectly through blood pressure regulation, it is not the primary therapeutic effect to monitor.
Correct Answer is A
Explanation
A. The nurse's role is to provide education and information about available methods of contraception without imposing personal beliefs or preferences.
B. It is not the nurse's role to select the method of contraception for the client. The decision should be made by the client based on their individual preferences and health considerations.
C. While assessing the client's socioeconomic status may be relevant for some aspects of care, it is not directly related to providing information about contraception.
D. Collecting a dietary history is not relevant to a client's inquiry about contraception.
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