While assessing a patient who gave birth 5 hours ago, the nurse finds that the woman has completely saturated: pad within 15 minutes. What is the nurse's first action?

Assess the woman's fundus and massage it if boggy

Assess the woman's pulse and BP for signs of hypovolemic shock

Call the woman's primary healthcare provider

Begin an IV infusion of Ringer's lactate solution and administer oxytocin

Answer and Explanation

The Correct Answer is A

A) Assess the woman's fundus and massage it if boggy:
A saturated pad within 15 minutes after delivery suggests a hemorrhage, and the first priority in this situation is to assess the fundus. If the fundus is boggy (soft and not contracted), it is a sign of uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contraction, which can help stop the bleeding.

B) Assess the woman's pulse and BP for signs of hypovolemic shock:
While it is important to monitor vital signs for signs of hypovolemic shock (e.g., increased heart rate, decreased blood pressure, and pale skin), this action would not be the first priority in managing a postpartum hemorrhage. The immediate focus should be on stopping the bleeding by addressing uterine atony. Hypovolemic shock assessment is important, but it comes after the initial steps of managing hemorrhage.

C) Call the woman's primary healthcare provider:
Calling the provider may be necessary if the bleeding does not stop after initial interventions. However, it should not be the first action. The nurse should first assess the uterus and attempt to stop the bleeding by massaging the fundus before calling the provider.

D) Begin an IV infusion of Ringer's lactate solution and administer oxytocin:
Starting an IV infusion and administering oxytocin may be part of the treatment for postpartum hemorrhage, but the first action should be to assess and manage the fundus. Oxytocin can help contract the uterus, but massaging the fundus is the immediate intervention. Intravenous fluids and medications should be initiated once the uterus is assessed and massaged, especially if bleeding persists.

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Correct Answer is D

Explanation

A. The fundus is palpable two fingerbreadths above the umbilicus:
While it is higher than expected, this finding may occur if the uterus is still contracting and involuting, as it can sometimes be positioned slightly higher. However, this is not necessarily a cause for concern, and further assessment would depend on other factors like bleeding or discomfort. If the fundus is firm and contractions are present, this finding may still be within a normal range.

B. The fundus is palpable at the level of the umbilicus:
At 12 hours postpartum, the fundus should generally be at the level of the umbilicus. This is an expected finding in the immediate postpartum period as the uterus is beginning to involute. No further action is required unless other complications, like excessive bleeding or signs of infection, are present.

C. The fundus is palpable one fingerbreadth below the umbilicus:
This is another typical finding 12 hours after birth. By this time, the uterus should be involuting and should be slightly below the umbilicus. A slight descent of the fundus is normal as the uterus shrinks and contracts. As long as the fundus is firm and there are no other concerning signs, this is a normal finding.

D. The fundus is palpable two fingerbreadths below the umbilicus:
A fundus palpated two fingerbreadths below the umbilicus 12 hours postpartum suggests that involution may not be progressing as expected. It could indicate uterine atony, where the uterus is not contracting effectively, increasing the risk for postpartum hemorrhage. This requires further assessment to rule out complications such as retained placental fragments or excessive bleeding. Immediate action, including uterine massage or other interventions, may be needed.

A. Keep umbilical cord dry and above the level of the diaper. B. Baby will need to breast feed every hour C. Be sure to always wrap baby in 2 blankets when going outside D. Limit the amount of time baby is skin to skin with parents

Correct Answer is A

Explanation

A) "Keep umbilical cord dry and above the level of the diaper."
The umbilical cord stump should be kept clean, dry, and exposed to air as much as possible to prevent infection. The diaper should be folded below the stump to ensure that it remains dry and doesn’t rub against it, which can lead to irritation or infection.

B) "Baby will need to breastfeed every hour."
Newborns typically breastfeed every 2 to 3 hours, not necessarily every hour. The exact frequency may vary based on the baby's hunger cues. Overstating the frequency of feedings may cause undue anxiety for parents, as newborns may not feed this frequently.

C) "Be sure to always wrap baby in 2 blankets when going outside."
Overbundling can lead to overheating. Newborns should be dressed in appropriate layers for the weather, with one layer more than an adult would wear. The use of two blankets may not be necessary unless it is extremely cold. The key is ensuring the baby is comfortably warm, not overheated.

D) "Limit the amount of time baby is skin to skin with parents."
Skin-to-skin contact is beneficial for newborns, especially in the early days after birth. It promotes bonding, stabilizes the baby’s body temperature, supports breastfeeding, and helps with the baby’s physiological stability. There is no need to limit skin-to-skin contact unless medically contraindicated.

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While assessing a patient who gave birth 5 hours ago, the nurse finds that the woman has completely saturated: pad within 15 minutes. What is the nurse's first action?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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