A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?
Measure the client’s vital signs.
Request the provider perform a vaginal examination.
Check the client’s fundus.
Feel for a full bladder.
The Correct Answer is C
Choice C rationale
Checking the fundus helps determine if the uterus is contracting properly, which is essential in managing postpartum bleeding.
Choice A rationale
Measuring vital signs is important but not the first action to control bleeding.
Choice B rationale
Requesting a vaginal examination is necessary but not the immediate action to control bleeding.
Choice D rationale
Feeling for a full bladder is important but not the first action to control bleeding.
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Correct Answer is D
Explanation
Choice D rationale
Using a postpartum depression-screening tool with the client is the first action the nurse should take. This tool helps to assess the severity of the client’s symptoms and determine the appropriate level of care. Early identification and intervention are crucial in managing postpartum depression effectively.
Choice A rationale
Arranging for counseling to help the client cope with the stress of being a parent is important, but it is not the first action. Counseling can be part of the treatment plan after the initial assessment using the screening tool.
Choice B rationale
Reinforcing teaching about ways to increase rest and sleep is beneficial for the client’s overall well-being, but it does not address the immediate need to assess the severity of the client’s depressive symptoms.
Choice C rationale
Requesting a prescription for an antidepressant medication may be necessary, but it should be based on the results of the screening tool and a thorough assessment by a healthcare provider.
Correct Answer is D
Explanation
Choice D rationale
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice A rationale
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Choice B rationale
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Choice C rationale
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.