Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.Which action should the nurse take?
Correct answer
A
Rationale
The correct action is A: Administer 500 mL lactated Ringer's IV bolus. This choice is correct because the patient may be experiencing hypovolemia post-surgery, requiring fluid resuscitation to maintain hemodynamic stability. Evaluating urinary output (B) is important but may not address the immediate need for fluid resuscitation. Applying an ice pack (C) may be indicated for pain management but does not address potential hypovolemia. Replacing the surgical dressing (D) is important for wound care but does not address the patient's fluid volume deficit.