Level: Advanced
Difficulty: Hard
Subtopic: Maternal emergencies
NCLEX: A postpartum client on the mother-baby unit is being evaluated for postpartum hemorrhage risk. Assessment data in…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for postpartum hemorrhage risk. Assessment data include fundus boggy above the umbilicus and deviated to the right with heavy lochia. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.