The first and most important nursing intervention when a nurse ...

[neverstopbelieb]

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:
 
  a. Call the woman's primary health care provider.
  b. Administer the standing order for an oxytocic.
  c. Palpate the uterus and massage it if it is boggy.
  d. Assess maternal blood pressure and pulse for signs of hypovolemic shock.

Question 2

When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is:
 
  a. Absence of cyanosis in the buccal mucosa.
  b. Cool, dry skin.
  c. Diminished restlessness.
  d. Urinary output of at least 30 mL/hr.

[reversalruiz]

Answer to Question 1

ANS: C
The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Although calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).

Answer to Question 2

ANS: D
Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

[neverstopbelieb]

Excellent

[jomama]

Gracias!