On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take?
Insert an indwelling catheter to empty the bladder and contract the fundus.
Check fundal consistency and continue to monitor the lochial flow amount.
Return the client to bed and maintain bedrest until the lochial flow slows.
Massage the fundus and avoid direct pressure on the cesarean incision.
The Correct Answer is D
This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding. Avoiding direct pressure on the incision prevents pain and wound dehiscence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When the PN witnesses a situation where a resident is shouting profanities and a staff member (UAP) responds inappropriately, the immediate priority is to ensure the safety and well-being of the resident. It is essential to address the situation promptly and prevent further escalation.
Entering the room and instructing the UAP to leave immediately serves several purposes:
1. Protecting the resident: Removing the UAP from the room ensures that the resident is not subjected to further conflict or distress.
2. Maintaining a calm and therapeutic environment: By addressing the disruptive behavior and removing the staff member involved, the PN can help restore a peaceful environment for the resident and other individuals in the facility.
3. Ensuring professional conduct: Shouting and engaging in unprofessional behavior is not acceptable in a healthcare setting. By immediately intervening and directing the UAP to leave the room, the PN reinforces the importance of maintaining a respectful and professional approach to caregiving.
After addressing the immediate concern, the PN should follow up by reporting the incident and providing a detailed account to the nurse manager or supervisor. This allows for appropriate action to be taken, such as further investigation or disciplinary measures if necessary.
The other options mentioned are not the first actions to be taken in this situation:
A. Reporting the incident and the UAP for further action by the nurse manager: While reporting the incident is important, it is not the immediate action required to address the situation in
real-time.
B. Telling both of them to lower their voices in consideration of other residents: While promoting a calm environment is important, addressing the issue of shouting and unprofessional behavior takes precedence over requesting a volume reduction.
C. Telling the resident and the UAP that shouting is not permitted: While it is essential to communicate the expectations of behavior, the immediate focus should be on removing the staff member from the situation and ensuring the resident's well-being.
Correct Answer is D
Explanation
A. C-reactive protein level:
C-reactive protein (CRP) is a marker of inflammation but does not specifically identify the causative organism of an infection. While elevated CRP can suggest infection or inflammation, it doesn't provide the necessary information for treatment.
B. Serum blood glucose (BG) level:
Serum blood glucose levels are important to monitor in diabetic patients because high glucose levels can impair healing and increase the risk of infection. However, it does not directly help identify the causative organism in this situation.
C. Serum albumin:
Serum albumin reflects nutritional status and can indicate malnutrition or poor wound healing. While it may be relevant for healing, it is not the most immediate test to evaluate for infection.
D. Culture for sensitive organisms:
Given the red, swollen wound with drainage and foul odor, a wound culture is the most appropriate first step to identify the specific infectious organism. This will guide the healthcare provider in selecting the most appropriate antibiotic treatment.
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