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
The correct answer and explanation is:
d) Massage the fundus and avoid direct pressure on the cesarean incision.
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.
a) Insert an indwelling catheter to empty the bladder and contract the fundus.
This is not the first action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Inserting an indwelling catheter requires a physician's order and may cause discomfort and infection. The client may already have a catheter in place after the surgery.
b) Check fundal consistency and continue to monitor the lochial flow amount.
This is not enough to do for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Checking fundal consistency and monitoring lochial flow are important, but they do not address the cause of bleeding or prevent further blood loss.
c) Return the client to bed and maintain bedrest until the lochial flow slows.
This is not appropriate for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Returning the client to bed and maintaining bedrest may delay ambulation and increase the risk of thromboembolism. It also does not stop the bleeding or treat the underlying cause.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c) Call the healthcare provider and clarify the prescription. Correct
This is the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage.
Calling the healthcare provider and clarifying the prescription is the safest and most effective way to prevent medication errors and ensure the child's safety. The PN should not administer the medication until they are sure that it is correct and appropriate for the child.
a) Tell the pharmacy to send an accurate child's dosage.
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage.
Telling the pharmacy to send an accurate child's dosage is not appropriate, as it may cause confusion, delay, or conflict with the healthcare provider's orders. The PN should not assume that they know the correct dosage for the child without consulting with the healthcare provider.
b) Ask another nurse if adult dosages are ever given to children.
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Asking another nurse if adult dosages are ever given to children is not helpful, as it may not provide accurate or reliable information.
The PN should not rely on another nurse's opinion or experience without verifying it with the healthcare provider.
d) Request verification of the prescription by the charge nurse.
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Requesting verification of the prescription by the charge nurse is not necessary, as it may waste time and resources.
The PN should be able to communicate directly with the healthcare provider and clarify any doubts or concerns about the prescription.
Correct Answer is A
Explanation
To calculate the amount of darbepoetin alfa that the nurse should administer, you can use the following formula:
Dose (mL) = Amount prescribed (mcg) / Concentration (mcg/mL)
In this case:
Amount prescribed = 40 mcg
Concentration = 60 mcg/mL
Dose (mL) = 40 mcg / 60 mcg/mL = 2/3 mL
Now, you can convert 2/3 mL to decimal to make it easier to work with:
2/3 = 0.6667 mL
Rounded to one decimal place, the nurse should administer approximately 0.7 mL of darbepoetin alfa. So, the correct answer is 0.7 mL.
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