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 C
Explanation
Mom's blood type is A-negative, and baby's blood type is O-positive would place the neonate at risk for physiologic jaundice due to Rh incompatibility. When mom is Rh-negative and baby is Rh-positive, the mother's immune system can create antibodies that attack the baby's red blood cells, leading to the destruction of red blood cells and subsequent release of bilirubin, which can result in jaundice.
Correct Answer is D
Explanation
Perineal hematoma is a complication that can occur after vaginal births, typically due to trauma or injury to the perineum during delivery. Wound dehiscence, UTIs, and DVTs are all possible complications associated with cesarean births. Wound dehiscence is a separation of the layers of the surgical incision, UTIs can occur due to catheterization during the surgery, and DVTs can occur due to immobility during the recovery period.
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