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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Choice B rationale
Folic acid is vital for preventing neural tube defects, including anencephaly. It’s recommended for women of childbearing age and especially during the early stages of pregnancy.
Choice C rationale
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Choice D rationale
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Correct Answer is B
Explanation
Choice A rationale
While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.
Choice B rationale
Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
Choice C rationale
Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.
Choice D rationale
Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.
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