A patient is in the immediate postpartum period after having delivered 9 pound. 14-ounce baby (4480 grams). iS 6. The patient is gravida 6, para 5. The nurse notices some new blood stains on the top sheets and discovers the patient lying in a pool of blood. The fundus is located above the umbilicus and is boggy. The bladder is not palpable. What would be the nurse's priority action?

Massage the fundus

Take the patient's blood pressure

Start an IV

Have the patient empty her bladder

Answer and Explanation

The Correct Answer is A

A) Massage the fundus:
The first priority in this situation is to massage the fundus to help control potential postpartum hemorrhage caused by uterine atony. A boggy fundus (soft and not firm) suggests that the uterus is not contracting effectively, which can lead to excessive bleeding. Massaging the fundus stimulates uterine contractions, which can help reduce bleeding by compressing the blood vessels that were supplying the placenta. The nurse should begin with this intervention immediately to address the most likely cause of the bleeding.

B) Take the patient's blood pressure:
While vital signs such as blood pressure are important for assessing shock or ongoing hemorrhage, massaging the fundus takes priority in this scenario to directly address the cause of the bleeding. Taking the blood pressure is not the most immediate intervention for this specific situation because the primary issue here is uterine atony, not hemodynamic instability (although it will need to be assessed shortly thereafter).

C) Start an IV:
Starting an IV may be important if there is significant blood loss, but it is not the first priority in this scenario. The nurse should first focus on stabilizing the uterus by massaging the fundus. IV access will become more critical if the bleeding is not controlled after the fundus is massaged and other interventions are required.

D) Have the patient empty her bladder:
While a full bladder can sometimes displace the uterus and cause it to be less effective at contracting, this is a secondary concern. The first priority is to address the uterine atony by massaging the fundus. Once the fundus is firm and bleeding is under control, the nurse can then consider having the patient empty her bladder to ensure it isn't interfering with the uterus' ability to contract.

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Correct Answer is ["A","C","D"]

Explanation

A) Clear fluids from airway:
Immediately clearing the infant's airway is one of the first steps in stabilizing the newborn after birth. This ensures the infant can breathe freely, reducing the risk of aspiration or airway obstruction. Suctioning the mouth and nose with a bulb syringe or suction catheter is the usual practice, especially if there are visible fluids or secretions. This intervention is critical for ensuring the infant's respiratory function.

B) Immediately assess and bathe baby:
While assessing the newborn is vital, it is not the immediate priority. The first step in stabilization is ensuring the newborn’s airway is clear, followed by efforts to prevent heat loss. Bathing should be delayed until after the baby is stable, and drying the baby thoroughly should be done as the first action to prevent hypothermia.

C) Dry infant thoroughly:
Drying the newborn thoroughly after birth is essential for preventing heat loss. Wet skin can quickly lead to hypothermia, and drying helps maintain the infant's body temperature. This intervention is vital for stabilizing the newborn and ensuring thermoregulation in the first moments of life.

D) Place baby skin to skin:
Skin-to-skin contact is a fundamental practice immediately after birth. It promotes bonding, helps regulate the infant's temperature, supports successful breastfeeding initiation, and stabilizes vital signs like heart rate and blood sugar levels. The mother’s body heat helps the baby maintain a normal temperature, which is especially important right after birth.

E) Give erythromycin ointment in baby’s eyes:
While applying erythromycin ointment to the baby’s eyes is a standard practice to prevent neonatal conjunctivitis (especially from gonorrhea or chlamydia), it is not a priority for immediate stabilization. This step is typically performed later, after the newborn is stable, and thermoregulation is addressed. The primary focus should be on airway clearance, drying, and promoting skin-to-skin contact first.

A. Apply ice to the perineal area for the first 12-24 hours. B. Apply warm packs to the perineal area for the first 24-48 hours. C. Encourage sitz baths at least twice a day D. Use a topical antiseptic cream or spray on the perineal area. E. Obtain an order for an indwelling urinary catheter.

Correct Answer is ["A","C"]

Explanation

A) Apply ice to the perineal area for the first 12-24 hours:
Applying ice to the perineal area in the first 12-24 hours after delivery is a common intervention for promoting comfort, especially for lacerations or episiotomies. The cold helps to reduce swelling and inflammation, and it numbs the area, providing pain relief. Ice also helps to constrict blood vessels, reducing blood flow to the affected area, which can prevent excessive bleeding and promote healing.

B) Apply warm packs to the perineal area for the first 24-48 hours:
Warm packs are generally not used in the first 24-48 hours after delivery for a laceration. Heat can increase blood flow, which is not ideal immediately after birth when the risk of swelling and bleeding is higher. Typically, warm packs are more beneficial after the first 48 hours to improve circulation and promote healing. Therefore, this is not the best intervention in the immediate postpartum period for a labial laceration.

C) Encourage sitz baths at least twice a day:
Sitz baths are highly effective for postpartum comfort, particularly for perineal trauma such as lacerations or episiotomies. A sitz bath helps to cleanse the area and promote relaxation, reducing discomfort. It also enhances circulation to the perineum, which can speed up healing. Encouraging sitz baths at least twice a day is a helpful intervention for postpartum care and is appropriate for a labial first-degree laceration.

D) Use a topical antiseptic cream or spray on the perineal area:
While topical antiseptics may help reduce infection risk, they are generally not necessary for most first-degree lacerations, especially if they are uncomplicated. In fact, overuse of antiseptics or antibiotic creams can irritate the sensitive tissue in the perineal area and delay healing. The focus should be on keeping the area clean and dry, using gentle care. Therefore, this intervention is not typically recommended for a labial laceration.

E) Obtain an order for an indwelling urinary catheter:
An indwelling urinary catheter is usually only needed in specific cases, such as when a woman is unable to void postpartum due to perineal trauma, epidural anesthesia, or bladder retention. In the case of a labial first-degree laceration, there is no indication for an indwelling catheter unless the woman is unable to void on her own. The best approach is to encourage frequent voiding and assist with comfortable positioning.

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Naxlex Comprehensive Predictor Exams

Name 3 nursing interventions that promote stabilization of the newborn immediately after birth:

Correct Answer is ["A","C","D"]

Explanation

Which of the following nursing interventions will promote comfort for a client with a labial first degree laceration? Select all that apply.

Correct Answer is ["A","C"]

Explanation

A nurse is giving discharge instructions to a new mother. What is the most important instruction to address the prevention of postpartum infection?

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