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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?

A.

Assess the client's blood pressure.

B.

Assess the bladder for distention.

C.

Massage the client's fundus.

D.

Prepare to administer a prescription.

E.

Prepare to administer a prescription.

Answer and Explanation

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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View Related questions

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale:

A postpartum temperature of 100.4°F (38.0°C) or higher may indicate an infection. Infections can occur after delivery, particularly if there was a manual extraction of the placenta, as in

this case. Close monitoring and further assessment are necessary to ensure the client does not develop sepsis or other complications.

Choice B rationale:

Fundal tone should be firm and well-contracted to prevent excessive bleeding postpartum. A boggy, midline fundus suggests that the uterus is not contracting effectively, increasing the

risk for postpartum hemorrhage. This requires immediate attention and intervention to ensure adequate uterine tone and control bleeding.

Choice C rationale:

Lochia should be monitored for quantity, color, and the presence of clots. Heavy lochia with small clots indicates that the client may be experiencing postpartum hemorrhage, which is a

significant concern. This can be related to uterine atony, retained placental fragments, or coagulopathies and warrants prompt evaluation and intervention.

Choice D rationale:

A respiratory rate of 17/min is within the normal adult range (12-20/min) and does not require follow-up. There are no signs of respiratory distress or abnormalities in this case, indicating

that the client's respiratory status is stable and does not necessitate further evaluation.

Choice E rationale:

A white blood cell count of 12,000/mm³ is within the expected range for postpartum women, where normal values can be elevated due to physiological stress and inflammation from

delivery. This level does not indicate infection or pathology and does not require follow-up in the context provided.

Choice F rationale:

Blood pressure of 144/92 mmHg is elevated and concerning, particularly in a postpartum client with a history of chronic hypertension and gestational diabetes. This could signal

postpartum preeclampsia or other hypertensive disorders, requiring careful monitoring and management to prevent complications like seizures, stroke, or organ damage.

Correct Answer is B

Explanation

Choice A rationale

Prophylactic treatment for cytomegalovirus during pregnancy isn't generally recommended. CMV detection should lead to close monitoring rather than prophylactic treatment, as

current treatments pose risks without guaranteed efficacy.

Choice B rationale

Avoiding cat litter is crucial during pregnancy to prevent toxoplasmosis infection, which can cause severe fetal harm, including hydrocephalus, mental disabilities, and seizures, by

transferring through contact with cat feces.

Choice C rationale

While avoiding crowded places can reduce general infection risks, it is not specifically associated with preventing TORCH infections. TORCH infections refer to a set of perinatal infections that pose particular risks to fetal health.

Choice D rationale

Rubella immunization should be done before pregnancy, not during, as live vaccines carry risks. A woman should confirm immunity before conception to protect against congenital rubella syndrome.

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