A nurse is caring for a client who is about to deliver a baby.
Which of the following responses should the nurse make?

The nurse should prepare for a cesarean birth

The nurse should check the client’s temperature every 8 hours

The nurse should encourage the client to empty the bladder every 2 hours

The nurse should remind the client to bear down with each contraction

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Cesarean birth is a surgical procedure that is only performed when there is a medical indication for it. It is not the standard of

care for all women who are about to deliver a baby.

In the absence of any specific information indicating a need for cesarean birth, it would be premature for the nurse to prepare

for one.

Choice B rationale:

Checking the client's temperature every 8 hours is part of routine postpartum care.

However, it is not a priority intervention during the active labor phase when the client is about to deliver.

The nurse's focus should be on supporting the client through the delivery process.

Choice C rationale:

Encouraging the client to empty the bladder every 2 hours is important for comfort and to prevent urinary retention.

However, it is not a priority intervention during the active labor phase.

The client may not feel the urge to urinate frequently due to the pressure of the baby's head on the bladder.

Choice D rationale:

Reminding the client to bear down with each contraction is the most appropriate nursing intervention at this time.

Bearing down helps to move the baby down the birth canal and can shorten the duration of labor.

The nurse can provide verbal cues and physical support to help the client bear down effectively.

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Correct Answer is D

Explanation

Choice A rationale:

Assisting the client to ambulate is not the immediate action required in this scenario. The nurse has found a small amount of

lochia rubra on the client’s perineal pad, and the fundus is midline and firm at the umbilicus. These are normal findings for a

client who is 4 hours postpartum. However, the nurse should ensure that there is no excessive bleeding, which could be a sign

of postpartum hemorrhage.

Choice B rationale:

Performing a fundal massage is not necessary in this case. Fundal massage is usually performed when the uterus is boggy or

soft, which could indicate uterine atony, a leading cause of postpartum hemorrhage. In this scenario, the fundus is firm and at

the level of the umbilicus, which is a normal finding 4 hours postpartum.

Choice C rationale:

Increasing the rate of IV fluids is not the immediate action required in this scenario. IV fluids are usually increased to expand

intravascular volume in cases of postpartum hemorrhage. In this case, the nurse has found a small amount of lochia rubra on

the client’s perineal pad, which is a normal finding 4 hours postpartum.

Choice D rationale:

Checking for blood under the client’s buttocks is the correct action for the nurse to take in this scenario. This is to ensure that

there is no excessive bleeding, which could be hidden under the client’s buttocks. Excessive bleeding could be a sign of

postpartum hemorrhage, a potentially life-threatening complication.

A. Check the client's blood pressure B. Massage the client's fundus C. Observe for pooling of blood under the buttocks D. Administer oxytocin

Correct Answer is B

Explanation

Choice A rationale:

Checking the client’s blood pressure is important, but it is not the first action the nurse should take. Hypotension could

indicate hemorrhage, but the nurse needs to address the immediate risk of excessive bleeding.

Choice B rationale:

The nurse should first massage the client’s fundus. A saturated perineal pad could indicate a postpartum hemorrhage.

Massaging the fundus helps the uterus contract and may stop the bleeding.

Choice C rationale:

Observing for pooling of blood under the buttocks is a way to assess for bleeding. However, this is not the first action because

it does not address the cause of the bleeding.

Choice D rationale:

Administering oxytocin can help the uterus contract and reduce bleeding. However, this is not the first action because it

requires a physician’s order.

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A nurse is caring for a client who is about to deliver a baby. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 4 hours postpartum.The nurse finds a small amount of lochia rubra on the client's perineal pad, and the fundus is midline and firm at the umbilicus.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 min.Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take?

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor.Which of the following findings confirm that the client is in labor?

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn.Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a client who is 8 hours postpartum and multiparous.Which of the following findings should alert the nurse to the client’s need to urinate?

A nurse is caring for a client 2 hours following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-minute period.Which of the following actions should the nurse take first?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?

A nurse is performing an assessment on a postpartum patient. The uterus is found to be displaced to the right.Which of the following actions should the nurse take?

A nurse is caring for a client who is about to deliver a baby.
Which of the following responses should the nurse make?