A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?

Explanation

Choice A Reason:

Applying an ice pack to the incision site may provide comfort but does not address the underlying cause of the vaginal bleeding. Additionally, applying cold therapy to the incision site may not be recommended immediately after surgery as it can interfere with wound healing.

Choice B Reason:

Administering 500 mL lactated Ringer's IV bolus is inappropriate. While administering IV fluids may be indicated in the management of postpartum hemorrhage to support intravascular volume, it should be based on a comprehensive assessment of the client's condition and vital signs, including blood pressure and heart rate. Administering fluids without a thorough evaluation may not address the underlying cause of the bleeding and could potentially exacerbate the situation.

Choice C Reason:

Evaluating urinary output is inappropriate. Steady vaginal bleeding that persists despite fundal massage after a cesarean birth may indicate postpartum hemorrhage (PPH). PPH is a serious complication that requires prompt assessment and intervention. One of the primary causes of PPH is uterine atony, which is when the uterus fails to contract adequately after delivery.

Choice D Reason:

Replacing the surgical dressing is inappropriate. While maintaining a clean and dry surgical dressing is important for wound care, it does not address the underlying cause of the vaginal bleeding. In this situation, the priority is to assess and manage the potential causes of postpartum hemorrhage, such as uterine atony and urinary retention.

Explanation

Choice A Reason:

Providing oxygen to the client via nonrebreather face mask is incorrect. Oxygen administration may be necessary if the client is hypoxic due to severe blood loss, but it is not the first action to address excessive vaginal bleeding.

Choice B Reason:

Emptying the client's bladder is incorrect. A full bladder can impede uterine contraction and contribute to postpartum hemorrhage. Emptying the bladder can help improve uterine tone and decrease bleeding. However, it is not the first action to take in the case of excessive vaginal bleeding.

Choice C Reason:

Administering oxytocin to the client is incorrect. Oxytocin is a uterotonic medication commonly used to promote uterine contraction and control postpartum bleeding. Administering oxytocin is an appropriate intervention for managing postpartum hemorrhage, but it may not be the first action to take.

Choice D Reason:

Massaging the client's fundus is correct. Massaging the client's fundus helps to stimulate uterine contractions, which can help control bleeding in the immediate postpartum period. Fundal massage is a standard intervention for managing postpartum hemorrhage and should be initiated promptly if excessive bleeding is noted.