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 A
Explanation
The correct answer is A. Two arteries and one vein.
A. Two arteries and one vein is the typical composition of the umbilical cord vessels. The umbilical arteries carry deoxygenated blood and waste products away from the fetus, while the umbilical vein carries oxygenated blood and nutrients to the fetus.
B. Two veins and one artery is not the usual configuration of the umbilical cord vessels. The presence of two veins is atypical.
C. One artery and one vein is an abnormal finding and may be associated with certain congenital anomalies or fetal abnormalities. This configuration is not the norm.
D. Two arteries and two veins is not a standard or physiological composition of the umbilical cord. The typical configuration is two arteries and one vein.
Correct Answer is B
Explanation
The correct answer is B. Massage the client's back.
A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.
B. Massage the client's back is consistent with the gate control theory of pain.
According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.
C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.
D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.
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