A nurse in a hospital is caring for a client who is 4 hour postpartum. Which of the following interventions should the nurse first perform after finding that the client's uterus is not firm? (Select All that Apply.)

Ask the client to empty their bladder

Perform fundal massage

Nothing, this is an expected finding

Ambulate the client in the hallway

Give pain medications

Answer and Explanation

Correct Answer : A,B

A) Ask the client to empty their bladder:
One of the first actions the nurse should take when the uterus is not firm (often referred to as uterine atony) is to ask the client to empty their bladder. A full bladder can interfere with uterine contraction and cause the uterus to be boggy or soft, which can lead to postpartum hemorrhage. Encouraging the client to void may help the uterus contract more effectively and reduce the risk of complications.

B) Perform fundal massage:
If the uterus is not firm, performing a fundal massage is essential. Fundal massage helps stimulate uterine contractions and helps the uterus contract to its normal size, reducing the risk of bleeding. It is a critical intervention in postpartum care to ensure that the uterus remains firm and does not become atonic, which can cause excessive blood loss.

C) Nothing, this is an expected finding:
A soft uterus (uterine atony) is not an expected finding 4 hours postpartum. A firm uterus is expected at this point to prevent hemorrhage. The nurse should take immediate action to address the issue of uterine atony, as failure to do so can lead to significant postpartum hemorrhage, a life-threatening complication.

D) Ambulate the client in the hallway:
Ambulation may be helpful later in the postpartum period to encourage circulation and prevent thromboembolism, but it is not a priority when the uterus is not firm. The first priority is to address uterine atony, and actions like emptying the bladder and massaging the fundus should be performed before ambulating the client.

E) Give pain medications:
While pain management is important, it is not the priority intervention when the uterus is not firm. The nurse must first address the cause of uterine atony (such as bladder distention) and stimulate uterine contractions via fundal massage to ensure that the uterus is firm and the client is not at risk for excessive bleeding. Pain medications can be given once the immediate uterine concerns have been addressed.

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Correct Answer is A

Explanation

A) A stool softener as needed:
Fibrinogen levels are elevated during pregnancy as part of the body's natural response to the increased risk of bleeding at birth. While this helps to prevent hemorrhage, it also increases the risk of clot formation, which can lead to postpartum complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). To prevent these complications, one recommended strategy is to use a stool softener. This helps prevent constipation, which can strain the body and increase the risk of developing blood clots due to the Valsalva maneuver during straining. Stool softeners reduce the likelihood of this strain, supporting overall circulation and reducing the risk of clotting.

B) Urinate every two to three hours:
While frequent urination is important for general bladder health, particularly in the immediate postpartum period to avoid urinary retention, it is not directly related to preventing complications associated with elevated fibrinogen levels. Fibrinogen's main risk is related to clotting, and frequent urination does not affect this process.
C) Eat a diet high in protein:
While eating a balanced diet with adequate protein is essential for postpartum recovery and tissue healing, it does not directly address the increased fibrinogen levels or the potential for clotting. A high-protein diet does not significantly reduce the risks related to hypercoagulability during the postpartum period, which is primarily managed through careful monitoring and preventive measures such as using stool softeners or encouraging movement.

D) Walk:
While walking is beneficial for overall health and can help improve circulation, reducing the risk of DVT and promoting postpartum recovery, walking alone may not be sufficient to counteract the increased clotting risk from elevated fibrinogen levels. While movement is important to prevent clots, the use of stool softeners to prevent constipation is a more direct and targeted intervention for preventing strain, which could trigger clot formation. Therefore, walking, while helpful, is not the most specific measure to prevent complications related to increased fibrinogen.

Correct Answer is ["5"]

Explanation

Given:

Desired dose: Digoxin 0.25 mg PO daily

Available concentration: Digoxin 500 mcg/10 mL

To find:

Volume to administer (in mL)

Step 1: Convert desired dose to micrograms

We know that 1 milligram (mg) is equal to 1000 micrograms (mcg). Therefore, to convert the desired dose from mg to mcg, we multiply by 1000:

Desired dose (mcg) = Desired dose (mg)x 1000

Desired dose (mcg) = 0.25 mg x 1000 = 250 mcg

Step 2: Set up the proportion

We can use the following proportion to solve the problem:

(Desired dose) / (Available concentration) = Volume to administer

Step 3: Substitute the values

Plugging in the given values, we get:

(250 mcg) / (500 mcg/10 mL) = Volume to administer

Step 4: Simplify

To simplify, we can invert the denominator and multiply:

(250 mcg) x (10 mL / 500 mcg) = Volume to administer

The "mcg" units cancel out, leaving us with:

(250 x 10 mL) / 500 = Volume to administer

Step 5: Calculate

Performing the multiplication and division, we get:

2500/ 500 = Volume to administer

5 mL = Volume to administer

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A nurse in a hospital is caring for a client who is 4 hour postpartum. Which of the following interventions should the nurse first perform after finding that the client's uterus is not firm? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is aware that fibrinogen levels are increased in pregnancy. Which measure can be taken to prevent postpartum complications that result because of this increase? Have the client:

Correct Answer is A

Explanation

A client is ordered digoxin 0.25mg po. daily. On hand is a liquid in a dropper bottle labeled 500mcg/10mL. How many milliliters will be administered?

Correct Answer is ["5"]

Explanation

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