Difficulty: Medium
Average Score: 73%
Simulated
Passage / Scenario
A client who is at 32 weeks of gestation and has placenta previa exhibiting a large amount of vaginal bleeding.Which of the following actions should the nurse take?
Correct answer
D
Rationale
The correct action for the nurse to take is to obtain serial hemoglobin and hematocrit levels. This is important for monitoring the patient's blood loss and hemodynamic status after childbirth. Serial monitoring helps in early detection of postpartum hemorrhage and guides appropriate interventions. Giving oxytocin 20 units IV bolus (choice A) is contraindicated as it can cause severe adverse effects like hypotension and cardiac arrhythmias. Performing a fundal massage (choice B) is a potential intervention for uterine atony but assessing for abdominal tenderness (choice C) would be more appropriate to identify possible causes of pain. Therefore, obtaining serial hemoglobin and hematocrit levels is the most appropriate action to assess and manage postpartum hemorrhage effectively.