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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","D","E","F"]

Explanation

B. Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.

D. Maintain an eye mask over the newborn's eyes.

E. Reposition the newborn every 2 hours.

F. Report sunken fontanels to the provider. Contraindicated:

A. Apply lotion to the skin every 4 hours.

C. Newborn feedings should be every 8 hours.

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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