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 A
Explanation
Choice A rationale
Measuring leg circumferences is a crucial intervention for a client with thrombophlebitis. This helps in monitoring for any increase in swelling, which can indicate worsening of the condition or the development of complications such as deep vein thrombosis (DVT). Regular measurement allows for early detection and timely intervention.
Choice B rationale
Massaging the affected extremity is contraindicated in clients with thrombophlebitis. Massage can dislodge a thrombus, leading to a potentially life-threatening pulmonary embolism. Therefore, this intervention should be avoided.
Choice C rationale
Applying cold compresses to the affected extremity is not recommended for thrombophlebitis. Cold compresses can cause vasoconstriction, which may worsen the condition by reducing blood flow and increasing the risk of clot formation.
Choice D rationale
Allowing the client to ambulate is not advisable in the acute phase of thrombophlebitis. Ambulation can increase the risk of thrombus dislodgement and subsequent pulmonary embolism. Bed rest with the affected limb elevated is usually recommended until the acute phase resolves.
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.