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 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.
Correct Answer is D
Explanation
Choice A rationale
Rho(D) immune globulin is not indicated if both the client and the newborn are Rh positive. There is no risk of Rh incompatibility in this scenario.
Choice B rationale
Similarly, if both the client and the newborn are Rh positive, there is no need for Rho(D) immune globulin.
Choice C rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.
Choice D rationale
Rho(D) immune globulin is indicated when the client is Rh negative and the newborn is Rh positive. This prevents the development of Rh antibodies in the client, which could affect future pregnancies.