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 ["A","B","C","D","E"]
Explanation
Choice A rationale
Postpartum blues typically resolve within the first two weeks postpartum and involve mild symptoms like mood swings and irritability. In contrast, postpartum depression can persist
longer and requires treatment.
Choice B rationale
Symptoms of postpartum blues usually disappear without medical intervention, whereas postpartum depression often needs professional treatment to manage the more severe and
persistent symptoms.
Choice C rationale
Postpartum depression can impair a mother's ability to care for herself and her baby safely, requiring intervention to prevent harm. Postpartum blues do not typically cause such severe
functional impairment.
Choice D rationale
Postpartum depression may require antidepressants for treatment due to its severity. Postpartum blues generally do not necessitate such interventions and are managed through
support and reassurance.
Choice E rationale
Postpartum depression can occur at any time within the first 12 months after delivery, while postpartum blues are usually confined to the initial two weeks postpartum.
Correct Answer is B
Explanation
Choice A rationale
Umbilical cord compression typically results in variable decelerations in the fetal heart rate, not moderate variability or regular accelerations. It can lead to changes in fetal heart rate
patterns, but not regular mild contractions.
Choice B rationale
Dysfunctional labor refers to an abnormal labor pattern, including irregular uterine contractions. The described symptoms fit this condition, as they can cause mild pain and be
managed by ambulation, showers, and rest.
Choice C rationale
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, leading to fever, uterine tenderness, and foul-smelling amniotic fluid, not mild contractions and moderate
variability in FHR.
Choice D rationale
Iron deficiency anemia in pregnancy can cause fatigue, pallor, and shortness of breath but does not affect uterine contractions or fetal heart rate.