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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 ["B","E","F"]

Explanation

Choice A rationale:

The statement suggests supplementing with formula due to the baby’s weight loss. However, a 5% weight loss in the first few days is normal for breastfed infants, and formula

supplementation is not necessary unless recommended by a healthcare provider. Early breastfeeding should be encouraged to increase milk supply and support newborn weight gain.

Choice B rationale:

This statement correctly indicates that newborns should feed 8 to 12 times per day and on demand to ensure adequate nutrition and promote milk production. Frequent breastfeeding

helps establish and maintain milk supply.

Choice C rationale:

Using plastic-lined breast pads can retain moisture and increase the risk of infection or irritation. Sore nipples can be managed with lanolin creams, air-drying, and proper latching

techniques during breastfeeding.

Choice D rationale:

Drinking more whole milk is a common misconception and does not directly increase a mother's milk supply. Milk production is influenced by frequent breastfeeding, proper hydration,

and balanced nutrition, not by specific types of foods or drinks.

Choice E rationale:

Newborn stools transition from dark greenish meconium to yellow, seedy stools within the first few days of life as breastfeeding becomes established. This indicates effective feeding

and milk intake.

Choice F rationale:

It is normal for a breastfeeding mother’s breasts to feel full, warm, and slightly tender as her milk comes in. This indicates that the milk supply is increasing and the body is responding

to the newborn’s feeding needs.

Correct Answer is D

Explanation

Choice A rationale

External fetal monitors are non-invasive and do not pose a risk of transmitting HIV from mother to baby. They are considered safe for monitoring fetal well-being in an HIV-positive mother.

Choice B rationale

Administering antiviral medication is essential in reducing the risk of mother-to-child transmission of HIV. It's a standard care practice for managing HIV-positive pregnant women.

Choice C rationale

Preparing for a caesarean section may be recommended to reduce the risk of vertical transmission of HIV during delivery, especially if the viral load is high.

Choice D rationale

Internal fetal scalp electrodes are contraindicated because they can create a portal for HIV transmission from mother to baby through small abrasions or punctures on the fetal scalp.

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