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
Open heart surgery is unrelated to the development of vaginal fistulas.
Choice B rationale
Tissue trauma from childbirth can cause vaginal fistulas, as prolonged labor or obstetric interventions can damage vaginal tissue and lead to fistula formation.
Choice C rationale
Diabetes mellitus does not directly cause vaginal fistulas, although it can affect overall tissue health and healing.
Choice D rationale
Preeclampsia, while a serious pregnancy complication, is not a direct cause of vaginal fistulas.
Correct Answer is B
Explanation
Choice A rationale
Precipitous labor is a rapid labor that typically lasts less than 3 hours. While it can result in trauma and complications, it does not inherently increase the risk for an operative delivery,
which is more often related to other factors like fetal distress or failure to progress.
Choice B rationale
Postpartum hemorrhage (PPH) is a significant concern with precipitous labor due to the rapid and forceful contractions that can cause uterine atony, leading to increased bleeding
after birth.
Choice C rationale
In a precipitous labor, the rapid delivery can cause vaginal lacerations, not a decreased risk. The swift passage of the baby through the birth canal increases the risk of tears and
trauma.
Choice D rationale
Neonatal sepsis is related to infections acquired during delivery but is not specifically linked to the speed of labor. The primary concern in precipitous labor is maternal trauma and
hemorrhage, not infection.