The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

Assess the vital signs.

Increase IV infusion rate.

Notify the healthcare provider.

Massage the fundus.

None

Answer and Explanation

The Correct Answer is D

Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.

Choice B rationale

Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.

Choice C rationale

Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.

Choice D rationale

Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.

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Correct Answer is C

Explanation

Choice A rationale

Infusing 1,000 mL normal saline using a large bore IV is a good response to increase the client's blood volume and improve blood pressure, but it should not be the first action. The immediate priority is to relieve the compression of the inferior vena cava caused by the gravid uterus, which is decreasing blood return to the heart and causing hypotension.

Choice B rationale

Obtaining a blood sample for a complete blood count is important for assessing the client's overall health and identifying any possible complications, but it does not address the immediate life-threatening issue of hypotension caused by the gravid uterus compressing the inferior vena cava.

Choice C rationale

Tilting the backboard sideways to displace the uterus laterally is the correct first action. This maneuver helps to relieve the compression of the inferior vena cava by the gravid uterus, thereby improving blood return to the heart, increasing cardiac output, and normalizing blood pressure.

Choice D rationale

Palpating the abdomen for contractions is important to assess for potential labor or uterine irritability, but it does not address the immediate need to relieve the compression of the inferior vena cava causing hypotension.

A. Encourage the client to drink 8 oz of water. B. Assist the client to left lateral tilt position. C. Prepare to draw blood for analysis. D. Apply an external fetal monitor to the abdomen.

Correct Answer is C

Explanation

Choice A rationale

Drinking water is not necessary before a triple screen analysis. This test does not require a full bladder.

Choice B rationale

The left lateral tilt position is typically used to prevent supine hypotensive syndrome in pregnant women during ultrasounds, not for a blood draw.

Choice C rationale

A triple screen analysis involves drawing blood from the mother to test for specific markers that indicate the risk of certain fetal abnormalities. Blood sampling is necessary for the analysis.

Choice D rationale

Applying an external fetal monitor is unrelated to a triple screen analysis, which focuses on maternal blood markers rather than fetal heart rate monitoring.

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The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

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Correct Answer is C

Explanation

In preparing a gravid client for a triple screen analysis, which action should the nurse take?

Correct Answer is C

Explanation

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