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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Applying a warm pack to the puncture site before the procedure increases blood flow to the area, which makes the blood sample collection easier and reduces discomfort for the newborn.
B. A mummy restraint may not be necessary for a routine blood glucose test. The nurse can gently hold the newborn in place during the procedure without needing to fully restrain them.
C. Antiseptic solution is typically applied before the puncture to cleanse the area. After the procedure, gentle pressure and bandaging are more appropriate to stop bleeding.
D. Elevating the extremity is unnecessary for a newborn blood glucose test, as warming the area is more effective in promoting blood flow to the puncture site.
Correct Answer is B
Explanation
A. The shoulder harness should be placed between the breasts and off to the side of the gravid uterus, not directly across it. This helps reduce the risk of injury in the event of a crash.
B. Moving the seat as far away as possible from the steering wheel reduces the risk of injury from the steering wheel or airbag impact while still allowing the client to drive safely.
C. The lap belt should be worn low across the hips and under the abdomen, not high across the abdomen, to protect the growing fetus and prevent harm during sudden deceleration.
D. Airbags should not be disabled as they provide essential protection during a crash. Proper seatbelt use and correct seating position allow airbags to function effectively without posing a risk to the pregnant client.
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