Exhibits

The nursing priority is to
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Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Incorrect. 200 mL of urine in 12 hours is inadequate postpartum output and may indicate urinary retention.

B. Correct. A distended bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The provider should be notified, and interventions such as catheterization may be necessary.

C. Incorrect. Waiting 24 hours before intervention is inappropriate when urinary retention is already evident.

D. Encouraging fluids is helpful, but it does not directly address the immediate concern of a distended bladder.

A. Administer acetaminophen for pain B. Encourage oral fluids C. Administer a sitz bath D. Administer an Enema

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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Exhibits The nursing priority is to dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at 12 hours postpartum who has voided a total of 200 ml. Upon assessment the nurse notes that the bladder is distended. What is the priority intervention by the nurse?

Correct Answer is B

Explanation

A nurse is reviewing the prescribed orders for a client who is two days postpartum and has a fourth degree perineal laceration. Which of these orders should the nurse question?

Correct Answer is D

Explanation

A nurse is assessing a client who is four hours postpartum. Her temperature is 39 C (102.2F), pulse 96 beats per minute, and respirations 18 breaths per minute. Based on this information, which of these orders is most appropriate for treating the client at this time?

The nurse can differentiate a new father is experiencing engrossment when she notices which behavior?

On the fourth postpartum day, a client experiences breast engorgement. To relieve her discomfort, which of these nursing interventions is most effective to meet the expected outcome?

The nurse assesses a mother's bonding with her new baby. Which action made by the mother does the nurse identify as the initial maternal phase/postpartum adjustment.

A breastfeeding mother expresses concern about whether her one-week-old newborn is getting enough milk. Which finding is a concrete indicator that the baby is getting enough milk?

A lactation consultant is conducting a teaching session with a new mother about breastfeeding. Which of the client responses would indicate the need for further teaching?

The nurse is administering Labetalol 40MG IV q4h. On hand is a 5ML multi-dose vial with a concentration of 5MG/ML. How many ML will the nurse administer every four hours?

The nurse is assessing a postpartum patient who had an uncomplicated vaginal delivery one hour ago. Which assessment finding requires immediate intervention?

Exhibits

The nursing priority is to
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