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
No explanation
Correct Answer is C
Explanation
The correct answer is C. Assess the fetal heart rate.
A. Providing clean, dry underpads is important for maintaining cleanliness and comfort, but it is not the priority immediately following an amniotomy.
B. Monitoring the client's temperature is a consideration but is not the priority immediately following an amniotomy. Assessing the fetal well-being takes precedence.
C. Assessing the fetal heart rate is the priority action.
Following an amniotomy, there is a risk of cord prolapse or compression, and assessing the fetal heart rate helps detect any signs of fetal distress or compromise.
D. Assessing the odor of the amniotic fluid may be relevant, but it is not the immediate priority after an amniotomy. Focusing on fetal well-being is crucial.
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