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 A

Explanation

A) Intracostal retractions:
Intracostal retractions indicate respiratory distress in the newborn and should be reported immediately to the neonatologist. Retractions occur when the muscles between the ribs (intercostal muscles) are drawn in with each breath, signifying increased effort to breathe. This could indicate a serious condition such as respiratory distress syndrome (RDS), pneumonia, or other respiratory compromise. This finding requires urgent assessment and potential intervention to ensure the neonate is receiving adequate oxygenation.

B) Caput succedaneum:
Caput succedaneum is a common and benign finding in newborns, especially after a vaginal delivery. It refers to a swelling of the soft tissue on the baby's head, often seen after prolonged labor or use of forceps during delivery. This condition is typically resolves on its own within a few days and does not require immediate intervention or reporting to the neonatologist.

C) Positive Babinski sign:
A positive Babinski sign (fanning of the toes when the sole is stroked) is a normal reflex in neonates and is expected up to about 2 years of age. It is part of the newborn's neurological development and indicates the functioning of the central nervous system. Therefore, this finding does not require reporting to the neonatologist.

D) Pink-tinged urine in the diaper:
Pink-tinged urine, also known as "brick dust" or uric acid crystals, is a common finding in the first few days of life. It is typically harmless and results from concentrated urine or from the breakdown of urates. It usually resolves as the newborn begins to consume more fluids and the urine becomes more diluted. This finding does not necessitate immediate reporting unless it persists or is associated with other symptoms.

A. Has at least six to eight wet diapers per day B. Sleeps for 6 hours at a time between feedings C. Gains 1 to 2 ounces per week D. Has at least one breast milk stool every 24 hours

Correct Answer is A

Explanation

A) Has at least six to eight wet diapers per day:
One of the most reliable signs of effective breastfeeding is adequate hydration and urine output, which can be assessed by the number of wet diapers. A well-fed infant should have at least six to eight wet diapers per day, indicating that they are taking in sufficient breast milk and are adequately hydrated. This is a key indicator of successful breastfeeding and helps to ensure that the baby is getting enough milk.

B) Sleeps for 6 hours at a time between feedings:
While it is normal for newborns to sleep, they should not go for long periods without feeding, especially in the early days of life. Newborns typically need to be fed every 2 to 3 hours, and a sleep pattern of 6 hours between feedings could be concerning, as it may indicate that the baby is not waking up frequently enough to eat. This could result in inadequate milk intake and dehydration. Breastfeeding on demand is important, and frequent feedings help to stimulate milk production.

C) Gains 1 to 2 ounces per week:
A typical weight gain for a newborn is about 4 to 7 ounces per week during the first few months of life. Gaining 1 to 2 ounces per week could be lower than expected, and while weight gain is an important indicator of breastfeeding effectiveness, it is not the most immediate or reliable sign in the first week, especially if the baby is otherwise feeding well and producing an adequate number of wet diapers.

D) Has at least one breast milk stool every 24 hours:
While it is normal for a newborn to have breast milk stools, the frequency can vary widely. Some infants may pass stools after every feeding, while others may have fewer. One stool every 24 hours is not necessarily a sign of inadequate breastfeeding, especially if the baby is having a good number of wet diapers. The stool pattern can differ from baby to baby, and as long as the infant is feeding well and producing sufficient wet diapers, stool frequency alone is not the best indicator of breastfeeding success.

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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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