# 陰道生產後二十分鐘，一名產婦出現大量陰道出血、子宮鬆軟、心跳每分鐘118次。護理師應優先採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=497626&lang=zh-tw > language: zh-TW > subject: Medical Emergencies > category: PA ## 題目 陰道生產後二十分鐘，一名產婦出現大量陰道出血、子宮鬆軟、心跳每分鐘118次。護理師應優先採取哪項行動？ ## 選項 1. 在進行任何子宮處置前，先檢查會陰是否有撕裂傷 2. 在通知產後出血應變小組前，先測量總失血量 3. 開始子宮按摩並啟動產後出血應變 **✔ 正確答案** 4. 協助產婦解尿，並在30分鐘後重新評估出血狀況 **正確答案: 3** ## 解析 大量出血合併子宮鬆軟，顯示產後出血可能與子宮收縮乏力有關。應開始子宮按摩並啟動出血應變，以便及時給予子宮收縮劑、傳明酸、輸液及評估出血來源。 ## 深入解析 快速解答 開始子宮按摩並啟動產後出血應變。子宮鬆軟合併大量出血及心跳每分鐘118次，需要立即進行協調性治療。 為什麼這是正確的 子宮鬆軟表示子宮收縮不足，導致胎盤附著處血管開放。現今產後出血照護強調早期辨識及快速組合式治療，包括子宮按摩、子宮收縮劑、傳明酸、靜脈輸液及檢查出血來源。 簡單比喻或心智圖像 收縮的子宮就像一個活體夾子，夾住胎盤血管。子宮鬆軟就像夾子鬆了，因此按摩有助於夾緊，同時整個出血團隊處理循環及其他原因；單靠按摩並非完整的組合式照護。 記憶掛鉤 大量出血加上子宮底鬆軟，表示現在就要按摩，現在就要啟動出血組合式照護。 NCLEX 決策規則 當產後出血量大且子宮鬆軟時，立即處理子宮收縮乏力，同時啟動出血處理流程。不要為了完成測量或單一原因檢查而延遲動員團隊。 為什麼其他選項是錯的 會陰撕裂傷評估很重要，但不應延遲對明顯子宮收縮乏力的立即處理。失血量測量應在出血應變已啟動的同時持續進行，而非在通報前完成；協助解尿可能幫助子宮位置，但對於活動性出血合併心搏過速來說太慢。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]WHO: Consolidated Postpartum Haemorrhage GuidelinesWorld Health Organization, FIGO, and ICM, 2025 ## 相同主題題目 - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw) - [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=zh-tw) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw) - [A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=374883&lang=zh-tw) - [A nurse is caring for a client prescribed Warfarin. Which nursing action is most appropria…](https://mymerci.kr/pages/nclex_q.php?qn_id=374884&lang=zh-tw) - [A nurse is caring for a client prescribed Heparin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=374893&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=497626&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=497626&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=497626&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=497626&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=497626&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_