Exhibits
The nursing priority is to
The Correct Answer is {"dropdown-group-1":"A"}
Massage the fundus: The client has heavy lochia rubra with clots, which indicates possible postpartum hemorrhage (PPH). A firm fundus does not rule out excessive bleeding, so fundal massage and further assessment are critical.
PPH is a life-threatening condition and must be addressed immediately.
Incorrect Answers & Rationale:
Encourage the client to ambulate: While ambulation is important postpartum, it is not the priority in the presence of heavy bleeding.
The client should remain in bed until bleeding is controlled.
Offer the client fluids: Fluids are beneficial but do not address the immediate concern of heavy bleeding. PPH requires active intervention, not just hydration.
Administer pain medication for postpartum discomfort: Pain relief is important, but postpartum hemorrhage is the priority. Uncontrolled bleeding is life-threatening and must be managed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Supporting the uterus decreases the amount of pain." Incorrect. While proper support may reduce discomfort, the primary reason is structural support.
B. "This is necessary because the ligaments that hold the uterus are stretched." Correct. The uterus is enlarged postpartum, and the ligaments are weakened, making support necessary.
C. "This will decrease the severity of uterine bleeding." Not the primary reason, though proper fundal massage can aid in hemorrhage prevention.
D. "This will help with uterine involution." Incorrect. Uterine involution is driven by hormonal changes and contractions, not just support.
Correct Answer is D
Explanation
A. Acetaminophen is an appropriate analgesic for postpartum pain relief.
B. Encouraging oral fluids is essential for hydration, bowel function, and healing.
C. A sitz bath is beneficial for perineal healing, reducing pain and inflammation.
D. Correct. Enemas are contraindicated in clients with fourth-degree perineal lacerations because they may cause trauma, pain, and further damage to the perineal area. Stool softeners are preferred to prevent straining.
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