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 D
Explanation
While gestational diabetes (GDM) can increase the risk of certain complications for the baby, such as macrosomia (large baby) and hypoglycemia after birth, there is no known increased risk for cardiac defects specifically. The other statements are accurate and appropriate for a client newly diagnosed with GDM.
Correct Answer is B
Explanation
Caput succedaneum is a common condition in newborns that causes swelling of the soft tissues of the scalp. It is usually caused by pressure on the baby's head during delivery and can be seen in both vaginal and instrumental births, such as vacuum-assisted deliveries. It generally crosses the suture lines, unlike a cephalohematoma.
Caput succedaneum is not a serious condition and generally resolves on its own within a few days without any treatment. However, the nurse should continue to monitor the newborn for signs of jaundice, which can occur due to the breakdown of red blood cells in the swelling.
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