A nurse is caring for a postpartum client who delivered vaginally yesterday and has been experiencing heavy vaginal bleeding since delivery.
Which of the following actions should the nurse take first?
Assess vital signs.
Palpate fundus.
Administer oxytocin as prescribed.
Check perineal pad.
The Correct Answer is B
The correct answer is B. Palpate fundus.
The nurse should first assess the fundus to determine if it is firm and at the expected level of involution.
A boggy or displaced fundus can indicate uterine atony, which is the most common cause of postpartum hemorrhage.
By massaging the fundus, the nurse can stimulate uterine contractions and reduce bleeding.
A. Assess vital signs.
This statement is wrong because assessing vital signs is not the first action the nurse should take.
Vital signs can indicate the severity of blood loss and shock, but they do not address the cause of bleeding.
C. Administer oxytocin as prescribed.
This statement is wrong because administering oxytocin is not the first action the nurse should take.
Oxytocin is a medication that can enhance uterine contractions and reduce bleeding, but it should be given after assessing and massaging the fundus.
D. Check perineal pad.
This statement is wrong because checking perineal pad is not the first action the nurse should take.
Checking perineal pad can help estimate the amount of blood loss, but it does not address the cause of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Massage her fundus.
This is because a boggy and displaced fundus indicates uterine atony, which is the failure of the uterus to contract sufficiently after delivery.
This can lead to excessive bleeding and postpartum hemorrhage.Massaging the fundus can help stimulate uterine contractions and reduce blood loss.
Choice A is wrong because administering oxytocin is not the first action the nurse should take.Oxytocin is a medication that can also help the uterus contract, but it should be given after massaging the fundus and assessing the bleeding.
Choice B is wrong because assisting with ambulation is not appropriate for a client with a boggy and displaced fundus.Ambulation can increase bleeding and cause orthostatic hypotension due to blood loss.
Choice C is wrong because encouraging frequent voiding is not the first action the nurse should take.
A full bladder can displace the uterus and prevent effective contractions, so voiding can help the uterus return to its normal position.However, this should be done after massaging the fundus and assessing the bleeding.
Correct Answer is D
Explanation
The correct answer is D) Decreased white blood cell count.Postpartum endometritis is an infection of the lining of the uterus that causes fever, abdominal pain, uterine tenderness and sometimes discharge.It is usually caused by bacteria from the lower genital or gastrointestinal tract.White blood cell count is a marker of inflammation and infection, so a decreased white blood cell count indicates that the treatment is effective and the infection is resolving.
A) Decreased vaginal bleeding is not a sign of effective treatment for postpartum endometritis.
Vaginal bleeding after delivery is normal and gradually decreases over time.It is not related to the infection of the uterus.
B) Increased abdominal pain is a sign of worsening infection, not effective treatment.Abdominal pain is one of the symptoms of postpartum endometritis and should improve with antibiotic therapy.
C) Increased temperature is also a sign of worsening infection, not effective treatment.Fever is another symptom of postpartum endometritis and should decrease with antibiotic therapy.
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.