Page 804 - Saunders Comprehensive Review For NCLEX-RN

which priority action in the care of the client?
1. Providing sitz baths
2. Encouraging fluid intake
3. Placing ice on the perineum
4. Monitoring hemoglobin and hematocrit levels
266. The nurse is monitoring a postpartum client who received epidural
anesthesia for delivery for the presence of a vulvar hematoma. Which
assessment finding would best indicate the presence of a hematoma?
1. Changes in vital signs
2. Signs of heavy bruising
3. Complaints of intense pain
4. Complaints of a tearing sensation
267. The nurse is creating a plan of care for a postpartum client with a small
vulvar hematoma. The nurse should include which specific action during the
first 12 hours after delivery?
1. Encourage ambulation hourly.
2. Assess vital signs every 4 hours.
3. Measure fundal height every 4 hours.
4. Prepare an ice pack for application to the area.
268. On assessment of a postpartum client, the nurse notes that the uterus feels
soft and boggy. The nurse should take which initial action?
1. Document the findings.
2. Elevate the client’s legs.
3. Massage the fundus until it is firm.
4. Push on the uterus to assist in expressing clots.

Answers

258. Answer: 2

Rationale: During the fourth stage of labor, the maternal blood pressure, pulse,
and respiration should be checked every 15 minutes during the first hour. An
increasing pulse is an early sign of excessive blood loss because the heart pumps
faster to compensate for reduced blood volume. A slight increase in temperature is
normal. The blood pressure decreases as the blood volume diminishes, but a
decreased blood pressure would not be the earliest sign of hemorrhage. The
respiratory rate is slightly increased from normal.
Test-Taking Strategy: Note the strategic word, early. Think about the
physiological occurrences of hemorrhage and shock and the expected findings in the
postpartum period. This should assist in directing you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Postpartum
Health Problem: Maternity: Postpartum Uterine Problems
Priority Concepts: Clotting; Perfusion
Reference: McKinney et al. (2018), p. 604.

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