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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence

Choice B Reason:

Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

Choice C Reason:

Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.

Choice D Reason:

Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.

A. "I will receive this medication if my baby is Rh-negative." B. "I will receive this medication when I am in labor." C. "I will need a second dose of this medication when my baby is 6 weeks old." D. "I will need this medication if I have an amniocentesis."

Correct Answer is D

Explanation

Choice A Reason:

"I will receive this medication if my baby is Rh-negative." This statement does not record understanding of the teaching. The purpose of Rho(D) immune globulin is to prevent sensitization of an Rh-negative mother to Rh-positive fetal blood. If the baby is Rh-negative, there is no need for Rho(D) immune globulin.

Choice B Reason:

"I will receive this medication when I am in labor." This statement does not record understanding of the teaching. Rho(D) immune globulin is typically given around 28 weeks of pregnancy and possibly after events that could lead to mixing of maternal and fetal blood, not specifically during labor.

Choice C Reason:

"I will need a second dose of this medication when my baby is 6 weeks old." This statement does not record understanding of the teaching. The administration of Rho(D) immune globulin is generally based on events during pregnancy and delivery, and a second dose is not typically given postpartum unless the baby is Rh-positive.

Choice D Reason:

"I will need this medication if I have an amniocentesis." This statement records understanding of the teaching. Rho(D) immune globulin is given to Rh-negative women during pregnancy and certain other situations to prevent the development of Rh incompatibility with a Rh-positive baby. If the mother undergoes procedures such as amniocentesis or experiences events that could lead to mixing of maternal and fetal blood, Rho(D) immune globulin is administered.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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