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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A rationale
The client needs a second varicella vaccination at her postpartum visit to ensure full immunity. The initial dose provides partial immunity, and the second dose completes the vaccination series.
Choice B rationale
The client needs to use contraception for 1 month, not 3 months, before considering pregnancy after receiving the varicella vaccine. This is to prevent potential harm to a developing fetus.
Choice C rationale
The varicella vaccine is not given based on the baby’s blood type. It is administered to protect the client from varicella infection.
Choice D rationale
There is no need for testing to see if the client has developed immunity after receiving the varicella vaccine. The second dose is given to ensure full immunity.
Correct Answer is C
Explanation
Choice A rationale
Checking blood pressure is important but not the first action to control bleeding.
Choice B rationale
Observing the client is necessary but not the immediate action to control bleeding.
Choice C rationale
Massaging the fundus helps the uterus contract and can reduce bleeding, which is crucial in managing postpartum hemorrhage.
Choice D rationale
Administering oxytocin is important but should follow fundal massage to ensure the uterus is contracting.