A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.
What action should the nurse take first?
Call the healthcare provider.
Encourage the client to void.
Administer ibuprofen 800 mg by mouth.
Increase the intravenous fluid to 150 mL/hour.
The Correct Answer is B
Choice A rationale
While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.
Choice B rationale
Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
Choice C rationale
Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.
Choice D rationale
Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.
Choice B rationale
Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.
Choice C rationale
Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.
Choice D rationale
While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.
Correct Answer is C
Explanation
Choice A rationale
Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.
Choice B rationale
A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.
Choice C rationale
A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.
Choice D rationale
Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.
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