A nurse is caring for a client who is 6 hours postpartum following a vaginal birth.
The client has saturated a perineal pad within 15 minutes.
Which of the following actions should the nurse take first?

Assess the client's blood pressure.

Assess the bladder for distention.

Massage the client's fundus.

Prepare to administer a prescription.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assessing the client's blood pressure can help determine if there is a significant loss of blood and consequent hypotension. However, it is not the immediate first action to manage heavy bleeding postpartum.

Choice B rationale

Assessing the bladder for distention is crucial as a full bladder can interfere with uterine contraction, potentially leading to increased bleeding. But, it isn't the first priority compared to addressing the immediate bleeding.

Choice C rationale

Massaging the client's fundus is the priority action in this case. It helps to contract the uterus, thereby reducing bleeding. Uterine atony is the most common cause of postpartum hemorrhage, and fundal massage is the first intervention to manage it.

Choice D rationale

Preparing to administer a prescription may be necessary, especially if uterotonics are required. However, this is a subsequent step after attempting to control the bleeding through fundal massage.

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Correct Answer is ["0724"]

Explanation

Step 1 is: October 17 + 7 days = October 24.

Step 2 is: October 24 - 3 months = July 24.

Step 3 is: July 24 + 1 year = July 24.

Answer: 0724 (July 24)

A. "It sounds like you are feeling sad that things didn't go as planned.”. B. "Maybe next time you can have a vaginal delivery.”. C. "At least you know you have a healthy baby.”. D. "You can resume sexual relations sooner than if you had delivered vaginally.”.

Correct Answer is A

Explanation

Choice A rationale

Acknowledging the client’s feelings provides emotional support and validates her experience. This response opens the door for further discussion and support, which is crucial for emotional well-being.

Choice B rationale

Suggesting future possibilities does not address the client's current emotional state. It may come across as dismissive of her feelings and does not offer the immediate support she needs.

Choice C rationale

While emphasizing the health of the baby is positive, it can also be perceived as dismissive of the client's feelings and her disappointment about the birth experience.

Choice D rationale

Mentioning the resumption of sexual relations shifts the focus away from her emotional needs and can be inappropriate or insensitive in this context, failing to address her disappointment.

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A nurse is caring for a client who is 6 hours postpartum following a vaginal birth.The client has saturated a perineal pad within 15 minutes.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on October 17. What is the client's EDB? (State the date in MMDD. For example, October 17 is 1017)

Correct Answer is ["0724"]

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who is 6 hours postpartum following a vaginal birth.
The client has saturated a perineal pad within 15 minutes.
Which of the following actions should the nurse take first?