On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:

massage the woman's fundus.

Begin an intravenous (IV) infusion of Ringer's lactate solution.

Call the woman's primary health care provider.

Assess the woman's vital signs.

Answer and Explanation

The Correct Answer is A

The nurse's first action should be to massage the woman's fundus. A completely saturated perineal pad within 15 minutes after giving birth indicates excessive bleeding, which is also known as postpartum hemorrhage (PPH). Massaging the uterus (fundus) can help it to contract, reduce bleeding, and prevent further blood loss. Once the fundus has been massaged, the nurse should assess the woman's vital signs and continue to monitor her for signs of continued bleeding. If bleeding persists despite massage, the nurse should begin an intravenous (IV) infusion of Ringer's lactate solution and call the woman's primary healthcare provider.

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Correct Answer is A

Explanation

Based on the provided information, the probable diagnosis for the spontaneous abortion in this woman would be a threatened abortion, since the cervix is closed and there is no evidence of expulsion of fetal or placental tissue. A threatened abortion is defined as vaginal bleeding occurring before the 20th week of gestation, with a closed cervical os, and no expulsion of fetal or placental tissue.

The other types of spontaneous abortion are defined as follows:

B. Inevitable abortion: vaginal bleeding and cramping with an open cervical os, with or without expulsion of fetal or placental tissue

C. Missed abortion: fetal demise without expulsion of fetal tissue, and may be associated with a closed cervical os and absence of uterine contractions

D. Incomplete abortion: partial expulsion of fetal or placental tissue, with or without vaginal bleeding, and may be associated with an open cervical os and uterine contractions

A. Preterm: Before 38 to 40 weeks of gestation if the infant is SGA post-term, beyond 40 to 42 weeks gestation if the infant is LGA B. Preterm: Before 37 weeks of gestation and post-term beyond 42 weeks of gestation; no matter the size for gestational age at birth C. Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA): beyond 42 weeks if the infant is AGA D. Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 57 weeks if the infant is small for gestational age (SCA)

Correct Answer is B

Explanation

The most accurate definition of preterm and post-term infants is based on gestational age at birth. Preterm infants are those born before 37 completed weeks of gestation, and post-term infants are those born after 42 completed weeks of gestation, regardless of their size for gestational age at birth.

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On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

For clinical purposes, the most accurate definition of preterm and post-term infants is defined as what?

Correct Answer is B

Explanation

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