A nurse is caring for a postpartum client who reports heavy vaginal bleeding and passing large clots since delivery 2 days ago.
Which of the following actions should the nurse take first?
Assess vital signs
Palpate fundus
dminister oxytocin as prescribed.
Check perineal pad.
The Correct Answer is B
The correct answer is choice B. Palpate fundus. The nurse should first assess the tone of the uterus by palpating the fundus, as uterine atony is the most common cause of postpartum hemorrhage.
If the uterus is boggy or soft, the nurse should massage it gently until it becomes firm and contracts.
This will help control the bleeding from the placental site.
Choice A is wrong because assessing vital signs is not the first priority in this situation. Vital signs may not reflect the severity of blood loss until late in the process of hemorrhage.
The nurse should monitor vital signs after ensuring that the uterus is contracted.
Choice C is wrong because administering oxytocin as prescribed is not the first action the nurse should take.
Oxytocin is a medication that stimulates uterine contractions and reduces bleeding, but it should be given
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["E"]
Explanation
Increased sleepiness and difficulty waking up are signs of central nervous system (CNS) depression in breastfed infants exposed to codeine through breast milk.Codeine is converted into morphine in the body, which can pass into breast milk and cause adverse effects in the baby.Codeine use by breastfeeding mothers can cause CNS depression in breastfed infants.
Therefore, the nurse should watch for increased sleepiness and difficulty waking up in the baby.
Choice A is wrong because increased alertness and activity are not signs of CNS depression.
They are more likely to be signs of stimulation or agitation.
Choice B is wrong because decreased appetite and weight gain are not specific signs of codeine exposure.
They can be caused by many other factors, such as illness, infection, or poor latch.
Choice C is wrong because increased respiratory rate and depth are not signs of CNS depression.
They are more likely to be signs of respiratory distress or infection.
Choice D is wrong because decreased heart rate and blood pressure are not signs of CNS depression.
They are more likely to be signs of shock or hypovolemia.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Respiratory rate: 30 to 60 breaths per minute
Correct Answer is B
Explanation
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.
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