A nurse is caring for a client who is postpartum. The client is experiencing excessive vaginal bleeding and has a boggy uterus. Which of the following actions should the nurse take first?
Apply oxygen via a non-rebreather mask at & L/min.
Administer methylergonovine 0.2 mg IM
Encourage the client to empty her bladder
Initiate fundal massage.
The Correct Answer is D
Rationale:
A) Incorrect - Applying oxygen is not the priority action in the case of excessive vaginal bleeding and a boggy uterus. Oxygen therapy would be appropriate if there were signs of respiratory distress or decreased oxygen saturation, but it does not directly address the primary concern of uterine atony and bleeding.
B) Incorrect - Administering methylergonovine might be appropriate, but the priority is to address the uterine atony with fundal massage first. Fundal massage helps stimulate uterine contractions and control bleeding, which is crucial in this scenario.
C) Incorrect - Encouraging the client to empty her bladder is important, but it is not the first action to take in the case of excessive bleeding and uterine atony. Immediate intervention to control the bleeding takes precedence.
D) Correct - Initiating fundal massage is the priority action in this situation. A boggy uterus with excessive vaginal bleeding indicates uterine atony, which is a potentially life-threatening condition requiring immediate intervention to prevent further bleeding.
Fundal massage helps the uterus contract and control bleeding. Addressing uterine atony is critical to prevent further hemorrhage and stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Amoxicillin is a safe and effective antibiotic for treating chlamydia infection in pregnant women.
B) Incorrect - Tetracycline and related antibiotics are often used to treat chlamydia, but they are contraindicated during pregnancy due to potential effects on fetal tooth and bone development. is contraindicated in pregnancy because it can cause fetal tooth discoloration and bone deformities.
C) Incorrect- Metronidazole is used for treating bacterial vaginosis and certain other infections, but it is not the first-line treatment for chlamydia.
D) Incorrect- Acyclovir is used to treat herpes simplex virus infections, not chlamydia.
Correct Answer is C
Explanation
A) Incorrect- Elevated blood pressure is not a primary risk associated with hyperemesis gravidarum.
B) Incorrect- Leukopenia (low white blood cell count) is not a common consequence of hyperemesis gravidarum.
C) Correct - Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy can lead to dehydration, which may affect amniotic fluid levels and result in hydramnios (excessive amniotic fluid).
D) Incorrect- Ketonuria (presence of ketones in the urine) is a possible consequence of excessive vomiting, but it's not the primary concern associated with hyperemesis gravidarum.
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