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 C
Explanation
A. Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B. Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C. A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D. Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.
Correct Answer is ["C","D","E"]
Explanation
A. Excessive lanugo:
This is incorrect. Excessive lanugo is more commonly seen in preterm newborns. Post-term newborns, such as those born at 43 weeks of gestation, typically have little to no lanugo due to its shedding during late gestation.
B. Hypotonia:
This is incorrect. Hypotonia (reduced muscle tone) is not a characteristic finding in post-term newborns. Post-term infants generally exhibit normal or increased muscle tone, unless there is an underlying condition or birth complication.
C. Absent vernix:
This is correct. Vernix caseosa, a protective substance that coats the skin in utero, is typically absent or minimal in post-term newborns because it is reabsorbed in the amniotic fluid as gestation progresses beyond term.
D. Dry, cracked skin:
This is correct. Post-term newborns often have dry, peeling, or cracked skin due to prolonged exposure to amniotic fluid. The lack of vernix exacerbates this condition, leading to skin that appears weathered or desquamated.
E. Long, hard nails:
This is correct. Post-term newborns frequently have long, hard nails that may extend beyond the fingertips. This is a result of extended fetal development time in utero
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.