A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following Interventions should the nurse perform?
Reassess the client in 2 hr.
Administer simethicone.
Assist the client to empty her bladder.
Instruct the client to lie on her right side.
The Correct Answer is C
Choice A Reason:
Reassess the client in 2 hours is inappropriate. While reassessment is important, addressing the cause of uterine displacement, in this case, a full bladder, should be the initial priority.
Choice B Reason:
Administering simethicone is inappropriate. Simethicone is typically used to relieve gas and bloating. It is not the primary intervention for uterine displacement related to bladder fullness.
Choice C Reason:
Assisting the client to empty her bladder is appropriate. A full bladder can displace the uterus and hinder its contraction, leading to potential issues such as uterine atony or increased postpartum bleeding. Emptying the bladder helps the uterus contract more effectively.
Choice D Reason:
Instructing the client to lie on her right side is inappropriate. Lying on the right side is often recommended to improve blood flow and oxygenation to the fetus during pregnancy but may not directly address uterine displacement caused by a full bladder. The priority is to assist the client in emptying her bladder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fetal lie being longitudinal is a normal and common fetal lie. It refers to the long axis of the fetus being parallel to the long axis of the mother.
B. Fetal position being persistent occiput posterior is a potential contributing cause.
Occiput posterior position (OP) can result in a more challenging and prolonged labor. This position, where the back of the baby's head is facing the mother's spine, is associated with increased back pain during labor.
C. Fetal attitude in general flexion is a favorable presentation for labor. Flexion allows for a smaller presenting diameter of the fetal head, facilitating descent through the birth canal.
D. Maternal pelvis being gynecoid is a favorable pelvic type for childbirth. The gynecoid pelvis is typically associated with easier labor and delivery.
Correct Answer is A
Explanation
The correct answer is A. Variable decelerations are due to umbilical cord compression.
A. Variable decelerations are often associated with umbilical cord compression. This compression can occur when the umbilical cord is briefly compressed or squeezed, leading to transient decreases in fetal heart rate.
B. Variable decelerations are not typically a result of the administration of IV narcotic analgesics. They are more commonly associated with cord compression or other factors affecting fetal oxygenation.
C. Variable decelerations are not generally caused by uteroplacental insufficiency. Uteroplacental insufficiency is more commonly associated with late decelerations.
D. Variable decelerations are not primarily related to fetal head compression. While head compression can cause certain types of decelerations, variable decelerations are specifically associated with umbilical cord compression.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today