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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
In the case of a prolapsed umbilical cord, the first priority intervention is to relieve pressure on the cord. Placing the woman in the knee-chest position or Trendelenburg position with the hips elevated is the best way to achieve this. This position helps to reduce the compression of the cord and improve fetal oxygenation.
Option B is incorrect because while oxygen may be necessary, relieving pressure on the cord is the priority.
Option C is incorrect because a vaginal birth should not proceed with a prolapsed umbilical cord, as it can cause cord compression and fetal distress.
Option D is incorrect because covering the cord in sterile gauze soaked in saline is not a priority intervention and may not be effective in relieving pressure on the cord.
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