Examkin

Soru

Zorluk: OrtaAnte/Intra/Postpartum and Newborn Care

A licensed practical nurse is collecting data from a client who is 12 hours postpartum following an uncomplicated vaginal delivery. The nurse observes that the client has completely saturated a perineal pad with lochia rubra over the past 45 minutes. Upon palpation, the uterine fundus is boggy and located 2 centimeters above the umbilicus. Which action should the nurse take first?

  1. Gently massage the client's uterine fundus until it becomes firm.Cevap
  2. B
    Administer a prescribed intravenous dose of a uterotonic medication.
  3. C
    Document the bleeding volume and fundal position as expected findings.
  4. D
    Notify the registered nurse immediately to prepare for a laceration repair.

Cevap

The correct action is to gently massage the client's uterine fundus until it becomes firm.
In the presence of a boggy (soft) uterus and heavy vaginal bleeding, the priority nursing action is to firmly but gently massage the fundus. This mechanical stimulation promotes immediate uterine contraction, which compresses the blood vessels at the placental site and controls postpartum hemorrhage caused by uterine atony. This is a primary, life-saving intervention that falls well within the practical nurse's scope of practice.

Adım Adım Çözüm

1
Analyze the client's clinical findings.
The combination of a pad completely saturated in under an hour and a boggy (soft), elevated fundus indicates excessive bleeding caused by uterine atony.
Identifying the physiological source of the bleeding is necessary to select the correct targeted intervention.
2
Determine the priority nursing intervention for uterine atony.
Fundal massage is identified as the immediate first-line action.
Manual stimulation forces the uterine muscles to contract, which mechanically compresses the bleeding blood vessels at the placental detachment site.
3
Evaluate the planned action against the practical nurse (PN) scope of practice.
Fundal massage is an essential, independent nursing action that is safely within the PN scope of practice.
The PN must act immediately to stop the bleeding using within-scope interventions before or while calling for additional registered nurse (RN) or provider assistance.

Anahtar Kavram

Postpartum Hemorrhage and Uterine Atony
Bu soruyu puanla

Konular

Ante/Intra/Postpartum and Newborn Care

Bu konudan daha fazla soru