The practical nurse (PN) is caring for a postpartum client who delivered 5 hours ago and has saturated a perineal pad with a few clots within 15 minutes.
Which action is most important for the PN to implement?
Increase the intravenous infusion rate.
Massage the fundus.
Notify the healthcare provider.
Assess the vital signs.
The Correct Answer is D
The most important action for the PN to implement is to **assess the vital signs**. Saturation of a peripad within 15 minutes to 1 hour after delivery must be promptly reported. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage¹. Early recognition and treatment of PPH are critical to care management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Fetal heart rate (FHR) is one of the essential indicators of fetal well-being during labor. A fall in FHR following each contraction is known as recurrent deceleration and can be an indication of fetal distress. In this case, the PN should first reposition the client laterally, as this may help to alleviate compression of the umbilical cord and improve fetal oxygenation.
A. Administering oxygen at 10 L/face mask may be necessary, but it is not the first intervention to be implemented in this scenario.
B. Discontinuing oxytocin infusion may be necessary, but it is not the first intervention to be implemented in this scenario.
C. Observing perineum for cord prolapse is not necessary in this scenario.
Correct Answer is C
Explanation
Answer: B. Limit play with the stuffed toy when out of the tent.
Rationale:
A) Spray the toy with disinfectant before placing it in the tent: Disinfecting the toy may not be necessary unless the toy is visibly soiled. Moreover, the use of disinfectants around the child may pose a risk of respiratory irritation, making this option inappropriate.
B) Limit play with the stuffed toy when out of the tent: This action is appropriate as it helps minimize the risk of cross-contamination and reduces exposure to potential allergens or irritants that may worsen the child's condition. Keeping the toy limited to the tent allows for a safer environment for the child.
C) Allow the child to have the stuffed toy in the tent: While having a favorite toy can provide comfort, it’s crucial to ensure that the toy does not harbor germs that could exacerbate the child's illness. In a mist tent, moisture can also promote mold growth on soft toys, so extra caution is necessary.
D) Ask the mother to wash the toy daily at home: While washing the toy is a good practice, this option does not directly address the immediate care in the hospital setting. Daily washing might not be feasible for the mother during the hospital stay, and it does not focus on minimizing exposure during the child’s hospitalization.
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