Difficulty: Medium
Average Score: 67%
Simulated
Passage / Scenario
The nurse is caring for a 31-year-old female client.Item 4 of 5
Orders
1345
ÔÇó Foley catheter
NursesÔÇÖ Notes
1300
Client is a 31-year-old G2P2 who delivered a healthy female infant (7 lb 14 oz) at 39 weeks gestation via spontaneous vaginal delivery. Labor was augmented with oxytocin, and the estimated blood loss at delivery was 400 mL. She was GBS positive and received appropriate antibiotic treatment during labor. Her obstetric history includes anemia during pregnancy and a prior vacuum-assisted delivery complicated by a retained placenta. At approximately one hour postpartum, the fundus is firm and midline at the level of the umbilicus, and lochia is moderate rubra. A second-degree perineal laceration was repaired with 2-0 vicryl. However, the client reports feeling light-headed, appears pale, and her peripad is saturated within 20 minutes.
1315
Client appears diaphoretic and states ÔÇ£I feel dizzy and something is wrong.ÔÇØ
On assessment, fundus is boggy, above the umbilicus, lochia is heavy, with large clots noted.
1350
Foley catheter placed without complication, pt tolerated well. Fundus remains boggy with moderate rubra bleeding.
The nurse is anticipating the initial interventions for the client. Select the three (3) priority interventions the nurse should anticipate the health care provider requesting for this client.
Correct answer
A, B, D
Rationale
Fundal massage (A), oxytocin infusion (B), and lactated ringers infusion (D) are priority interventions for postpartum hemorrhage. Fundal massage and oxytocin promote uterine contraction to control bleeding, while lactated ringers restore fluid volume. Hysterectomy (C) is a last resort, and intravenous albumin bolus (E) is less urgent in initial management.