The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
Hemoglobin and hematocrit
Abdominal contour and bowel sounds
Heart rate and blood pressure
Urinary output and IV fluid intake
The Correct Answer is C
A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.
B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.
C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.
D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.
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Related Questions
Correct Answer is C
Explanation
A. Schedule an appointment for the client with the diabetic nurse educator:
This could be a helpful action. The diabetic nurse educator can provide valuable support and education on managing insulin needs during breastfeeding.
B. Counsel her to increase her caloric intake:
While adequate nutrition is essential, increasing caloric intake may not be the primary factor affecting insulin needs. It's important to consider the specific needs of the client, and any adjustments to insulin should be made based on careful monitoring.
C. Inform her that a decreased need for insulin occurs while breastfeeding:
This is accurate information. Breastfeeding can lead to a decreased need for insulin in some individuals. The nurse should provide education on this aspect of managing diabetes during breastfeeding.
D. Advise the client to breastfeed more frequently:
While breastfeeding frequency can impact insulin needs, it's essential to consider the overall picture. Simply increasing breastfeeding frequency may not be the only factor affecting insulin requirements.
Correct Answer is A
Explanation
Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.
Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.
Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.
Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.
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