A nurse is caring for a client who is 6 hours postpartum following a vaginal birth.
The client has saturated a perineal pad within 15 minutes. Which of the following actions should the nurse take first?
Assess the client's blood pressure.
Assess the bladder for distention.
Massage the client's fundus.
Prepare to administer a prescription.
Prepare to administer a prescription.
The Correct Answer is C
Choice A rationale
Assessing the client's blood pressure can help determine if there is a significant loss of blood and consequent hypotension. However, it is not the immediate first action to manage
heavy bleeding postpartum.
Choice B rationale
Assessing the bladder for distention is crucial as a full bladder can interfere with uterine contraction, potentially leading to increased bleeding. But, it isn't the first priority compared to
addressing the immediate bleeding.
Choice C rationale
Massaging the client's fundus is the priority action in this case. It helps to contract the uterus, thereby reducing bleeding. Uterine atony is the most common cause of postpartum
hemorrhage, and fundal massage is the first intervention to manage it.
Choice D rationale
Preparing to administer a prescription may be necessary, especially if uterotonics are required. However, this is a subsequent step after attempting to control the bleeding through
fundal massage.
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Correct Answer is B
Explanation
Choice A rationale
The supine position is not recommended for breastfeeding because it can lead to issues with latching and milk flow, making it uncomfortable and potentially unsafe.
Choice B rationale
The cradle position is a common and effective breastfeeding position where the baby's head rests in the crook of the mother's arm, allowing for close contact and support.
Choice C rationale
Upright with chin support is not a standard breastfeeding position and may not provide the necessary support or alignment for effective breastfeeding.
Choice D rationale
Over-the-shoulder is also not a recommended breastfeeding position as it is impractical and does not facilitate proper latching or feeding.
Correct Answer is C
Explanation
Choice A rationale
Category 1 is a normal fetal heart rate pattern with no signs of fetal distress, which is not applicable in this case.
Choice B rationale
Category 2 represents an intermediate category with some concerns, but recurrent late decelerations and absent variability place this scenario in a higher risk category.
Choice C rationale
Category 3 indicates abnormal fetal heart rate patterns, including absent variability with recurrent late decelerations, which is associated with potential fetal hypoxia or acidemia and requires prompt intervention.
Choice D rationale
There is no Category 4 in fetal heart rate monitoring.