A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is found to be displaced laterally to the right, and there is uterine atony. Which of the following is the cause of the uterine atony?

Urinary retention

Poor involution

Infection

Hemorrhage

Answer and Explanation

The Correct Answer is A

Choice A rationale
Uterine atony refers to a soft and weak uterus after childbirth. It happens when your uterine muscles don’t contract enough to clamp the placental blood vessels shut after childbirth. This can lead to life-threatening blood loss after delivery. One of the causes of uterine atony is urinary retention. When the bladder is full, it can displace the uterus, preventing it from contracting properly. This can lead to uterine atony and postpartum hemorrhage. Therefore, urinary retention can cause uterine atony and lateral displacement of the fundus.
Choice B rationale
Poor involution of the uterus is a condition where the uterus does not return to its normal size after childbirth. While poor involution can lead to prolonged bleeding, it does not directly cause uterine atony. Uterine atony is specifically a lack of muscle contraction, while poor involution is a failure of the uterus to reduce in size.
Choice C rationale
While infection can lead to many complications during the postpartum period, it is not a direct cause of uterine atony. Infections can cause endometritis, which is inflammation of the uterine lining, but this does not prevent the uterus from contracting.
Choice D rationale
Hemorrhage, or heavy bleeding, is a result of uterine atony, not a cause. When the uterus does not contract properly after childbirth, it can lead to excessive bleeding, or hemorrhage.

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Correct Answer is B

Explanation

Choice A rationale
While an ASO titer test can be used in the diagnosis of rheumatic fever, it does not directly indicate if a child has rheumatic fever. Rheumatic fever is a complication that can occur after a streptococcal infection, and it involves multiple systems in the body, not just the presence of streptococcal antibodies.
Choice B rationale
An ASO titer test measures the antibodies produced by your body in response to a toxin known as streptolysin O, which is produced by group A Streptococcus (GAS) bacteria. Your body makes the antistreptolysin O antibodies when you have a strep infection caused by GAS bacteria. Therefore, a positive ASO titer test can confirm if your child had a recent streptococcal infection.
Choice C rationale
An ASO titer test does not measure the blood level of an aminoglycoside or any other therapeutic drug. Aminoglycosides are a class of antibiotics used to treat bacterial infections, and their levels in the blood are typically monitored with specific drug level tests, not an ASO titer.
Choice D rationale
An ASO titer test does not confirm if your child has immunity to streptococcal bacteria. The presence of ASO antibodies indicates a recent infection, but it does not provide information about the immune status or protection against future infections.

A. Expect some breast dimpling or discharge with age. B. Using the palm of the hand, feel for lumps using a circular motion. C. Breasts can be examined in the shower with soapy hands. D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.

Correct Answer is C

Explanation

Choice A rationale
While it’s true that some changes in the breast, such as dimpling or discharge, can occur with age, these are not normal and could be signs of a serious condition like breast cancer.
Therefore, this instruction should not be included in the pamphlet.
Choice B rationale
While using the palm of the hand to feel for lumps using a circular motion is a common method, it’s not the most effective. The pads of the three middle fingers should be used instead, as they are more sensitive to changes in the breast tissue.
Choice C rationale
This is the correct answer. Performing a breast self-exam in the shower with soapy hands is recommended because the soap helps your fingers glide smoothly over your skin, making it easier to feel for any lumps or changes.
Choice D rationale
While it’s true that women who have a menstrual cycle should perform a breast self-exam every month, the timing suggested here is not accurate. The best time to perform a breast self- exam is a few days after the menstrual period ends, when the breasts are less likely to be tender or swollen.

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A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is found to be displaced laterally to the right, and there is uterine atony. Which of the following is the cause of the uterine atony?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. What should the nurse respond?

Correct Answer is B

Explanation

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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