A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply.)

Document fundal height

Observe the lochia during palpation of fundus

Massage a firm fundus

Determine whether the fundus is midline

Administer terbutaline if the fundus is boggy

Answer and Explanation

Correct Answer : A,B,D

Choice A:

Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.

Choice B:

Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.

Choice C:

Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.

Choice D:

Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.

Choice E:

Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason:

Swimming is one of the best exercises for pregnant women because it provides moderate aerobic conditioning with minimal stress on your joints. It also supports your increased weight and helps you stay cool and comfortable.

Choice B reason:

Scuba diving is not a safe exercise for pregnant women because it poses a high risk of injury to the baby. The baby has no protection against decompression sickness and gas embolism, which are caused by changes in pressure underwater.

Choice C reason:

Walking is a great exercise for beginners and can be done throughout pregnancy. It improves your cardiovascular fitness, strengthens your muscles and bones, and helps prevent excessive weight gain and gestational diabetes.

Choice D reason:

Yoga can be beneficial for pregnant women as it can improve flexibility, balance, posture, breathing and relaxation. It can also reduce stress, anxiety and back pain. However, some yoga poses may not be suitable for pregnancy, so it is advisable to join a prenatal yoga class or consult a qualified instructor.

Choice E reason:

Snow skiing is not recommended for pregnant women because it involves a high risk of falling and affecting your balance. Falls can cause damage to your baby or placenta, especially in the second and third trimesters.

A. Monitor the newborn's blood glucose level hourly. B. Apply lotion to the newborn's skin twice per day. C. Maintain the newborn in a prone position D. Encourage the newborn to breastfeed every 2 hr.

Correct Answer is D

Explanation

Choice A reason:

Monitoring the newborn's blood glucose level hourly is not necessary for a newborn undergoing phototherapy. Phototherapy does not affect blood glucose levels, and hourly monitoring would be too invasive and stressful for the newborn. •

Choice B reason:

Applying lotion to the newborn's skin twice per day is not recommended for a newborn undergoing phototherapy. Lotion can interfere with the effectiveness of the phototherapy and increase the risk of skin irritation or infection. •

Choice C reason:

Maintaining the newborn in a prone position is not advisable for a newborn undergoing phototherapy. The newborn should be positioned on alternate sides to expose as much skin surface as possible to the light source. •

Choice D reason:

Encouraging the newborn to breastfeed every 2 hr is an appropriate action for a newborn undergoing phototherapy. Frequent feeding helps to promote hydration and the elimination of bilirubin from the body.

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A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Forms of exercise appropriate for a pregnant patient are? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

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