The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.
Her uterus is firm, and she has a moderate flow of lochia.
Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

Heart rate and blood pressure.

Urinary output and IV fluid intake.

Hemoglobin and hematocrit levels.

Abdominal contour and bowel sounds.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client’s heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.

Choice B rationale

While monitoring urinary output and IV fluid intake can be important in the overall assessment of a postpartum client, these are not the most immediate concerns when a perineal hematoma is forming.

Choice C rationale

Checking hemoglobin and hematocrit levels can provide information about the client’s blood volume and potential blood loss. However, this would likely be done after initial vital signs are assessed and stabilized.

Choice D rationale

Assessing abdominal contour and bowel sounds would not be the most immediate concern in this situation. These assessments would be more relevant if there were concerns about postpartum complications related to the client’s gastrointestinal system.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.

Choice B rationale

While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.

Choice C rationale

Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.

Choice D rationale

Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.

A. Take acetaminophen. B. Come in for an immediate evaluation. C. Monitor the flow of the vaginal bleeding. D. Rest in a supine position at home.

Correct Answer is B

Explanation

Choice A rationale

While acetaminophen can help reduce fever, it does not address the underlying cause of the client’s symptoms. Moreover, self-medication without proper medical advice can potentially harm the pregnancy.

Choice B rationale

The client’s symptoms of low-grade fever, moderate cramping, and heavy bright-red bleeding could indicate a serious condition such as a miscarriage or an ectopic pregnancy. Therefore, immediate medical evaluation is necessary.

Choice C rationale

While monitoring the flow of vaginal bleeding can provide useful information, it does not address the immediate need for medical evaluation given the client’s symptoms.

Choice D rationale

Resting at home might not be the best advice given the severity of the client’s symptoms. Immediate medical evaluation is necessary.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery. What should be the nurse’s initial action?

Correct Answer is A

Explanation

A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding.What advice should the nurse give the client?

Correct Answer is B

Explanation

The nurse is providing preconception counseling.Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer’s 1 liter. How many mL/hour should the nurse program the infusion pump to deliver? .

What is the most crucial assessment for the nurse to perform after administering epidural anesthesia to a patient who is at 40 weeks gestation?

A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

A client at 35 weeks gestation complains of pain whenever the baby moves.The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.What condition do these findings suggest?

An infant, born yesterday and initially weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today. What action should the nurse take?

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.
Her uterus is firm, and she has a moderate flow of lochia.
Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?