Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
69. A client, who is gravida 8, para 7, has saturated three perineal pads with bright red blood during the first hour after delivery. What are appropriate nursing actions for this client? Select all that apply.
. Administer oxytocin.
. Massage the fundus.
. Have the client empty her bladder.
. Administer tocolytics.
. Check vital signs.
Test-Taking Tip
Remember that tocolytics are used for preterm labor to decrease hyperstimulation in labor, and not used in clients who are postpartum.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because administering oxytocin can decrease the bleeding after delivery. Answer 2 is correct because massaging the fundus is the first step to decrease the bleeding. Making sure the fundus is firm and not deviated is an important postpartum assessment. Answer 3 is correct because a full bladder can impede the contraction of the uterus and can cause increased bleeding. Having the client empty her bladder can help decrease uterine bleeding. Answer 4 is incorrect because tocolytics are drugs that reduce contractions in preterm labor clients. Tocolytics would be contraindicated in a client who is postpartum and actively bleeding. Answer 5 is correct because vital signs are an important assessment for a client who is postpartum and having a large amount of bleeding. Changes in the heart rate and blood pressure can indicate significant blood loss.