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More questions ( 20 Questions)
A nurse is caring for a postpartum client who delivered vaginally yesterday and has been experiencing heavy vaginal bleeding since delivery.
Which of the following actions should the nurse take first?
This statement is wrong because assessing vital signs is not the first action the nurse should take.
Vital signs can indicate the severity of blood loss and shock, but they do not address the cause of bleeding.
The nurse should first assess the fundus to determine if it is firm and at the expected level of involution.
A boggy or displaced fundus can indicate uterine atony, which is the most common cause of postpartum hemorrhage.
By massaging the fundus, the nurse can stimulate uterine contractions and reduce bleeding.
This statement is wrong because administering oxytocin is not the first action the nurse should take.
Oxytocin is a medication that can enhance uterine contractions and reduce bleeding, but it should be given after assessing and massaging the fundus.
This statement is wrong because checking perineal pad is not the first action the nurse should take.
The correct answer is B. Palpate fundus.
The nurse should first assess the fundus to determine if it is firm and at the expected level of involution.
A boggy or displaced fundus can indicate uterine atony, which is the most common cause of postpartum hemorrhage.
By massaging the fundus, the nurse can stimulate uterine contractions and reduce bleeding.
A. Assess vital signs.
This statement is wrong because assessing vital signs is not the first action the nurse should take.
Vital signs can indicate the severity of blood loss and shock, but they do not address the cause of bleeding.
C. Administer oxytocin as prescribed.
This statement is wrong because administering oxytocin is not the first action the nurse should take.
Oxytocin is a medication that can enhance uterine contractions and reduce bleeding, but it should be given after assessing and massaging the fundus.
D. Check perineal pad.
This statement is wrong because checking perineal pad is not the first action the nurse should take.
Checking perineal pad can help estimate the amount of blood loss, but it does not address the cause of bleeding.