When caring for a postpartum client, the nurse notes that the client's perineal pad is saturated with bright red blood.
What is the priority to ask the client?
When was the last time you changed your pad?
Have you passed any clots?
Are you having any cramping?
Do you have to go to the bathroom? .
The Correct Answer is A
Choice A rationale
Determining the time of the last pad change assesses the rate of bleeding, which is crucial for evaluating postpartum hemorrhage. Bright red blood saturation indicates active bleeding, requiring quantification. If pads are saturated within an hour, immediate intervention is needed to prevent hypovolemic shock.
Choice B rationale
Asking about clots identifies uterine atony or retained placental fragments. However, it does not prioritize the bleeding rate assessment, which is critical for immediate hemodynamic stability and guides urgency in management.
Choice C rationale
Cramping indicates uterine contractions aiding involution. While helpful for understanding uterine activity, it does not directly evaluate the severity or rate of blood loss, which poses an immediate risk to the client’s life.
Choice D rationale
Checking for the need to urinate helps assess bladder distension. A full bladder inhibits uterine contraction, worsening atony-related bleeding. Still, this line of questioning is less critical compared to assessing the bleeding's rate and volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Difficulty feeding in infants can result from fatigue caused by inadequate oxygen delivery to tissues due to heart failure. Feeding is a demanding activity that requires energy and coordination, making it an early symptom of cardiac compromise in pediatric patients.
Choice B rationale
Wheezes or rales are caused by pulmonary congestion or edema, which occur in heart failure due to increased pulmonary venous pressure. This congestion results in fluid accumulation in the alveoli, leading to abnormal breath sounds. These findings require prompt evaluation.
Choice C rationale
Edema in the feet and legs results from systemic venous congestion caused by right-sided heart failure. Increased hydrostatic pressure in peripheral veins leads to fluid leakage into interstitial spaces, causing swelling, especially in dependent areas.
Choice D rationale
Tachypnea occurs as a compensatory mechanism in heart failure. Poor cardiac output reduces oxygen delivery, triggering the respiratory center to increase the breathing rate to improve oxygen uptake and delivery. It is an early sign of cardiopulmonary compromise in children.
Correct Answer is A
Explanation
Choice A rationale
Massaging the fundus is the first-line intervention when the fundus is soft and spongy, indicating uterine atony. Massage stimulates uterine contractions, reducing postpartum bleeding and restoring uterine tone, which is crucial to prevent hemorrhage.
Choice B rationale
Notifying the healthcare provider is necessary if initial interventions fail to address uterine atony. However, immediate action such as massaging the fundus should be taken first to minimize bleeding risks and stabilize the client.
Choice C rationale
Documenting fundal height and consistency is important but not an immediate intervention. Recording observations without addressing the atony fails to prevent potential complications like postpartum hemorrhage, which requires prompt and active management.
Choice D rationale
Administering Oxytocin as per MD orders aids uterine contraction but is not the first intervention. Massaging the fundus provides immediate mechanical stimulation to contract the uterus, a vital step before pharmacological measures are considered.
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