A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

Oﬀer clear liquids.

Auscultate the client's abdomen.

Check the client's chart for a diet prescription.

Give the client soda crackers.

Answer and Explanation

The Correct Answer is B

Choice B reason:
Auscultating the client's abdomen is the first action the nurse should take, as it can assess the return of bowel function after surgery. The nurse should listen for bowel sounds in all four quadrants, and note their frequency and quality.

Oﬀering clear liquids is an important action, as it can provide hydration and nutrition for the client. However, this is not the first action the nurse should take, as it may cause nausea and vomiting if the client's bowel function has not returned.

Choice C reason:
Checking the client's chart for a diet prescription is an important action, as it can ensure that the client follows the provider's orders and does not consume anything contraindicated. However, this is not the first action the nurse should take, as it does not address the client's hunger or bowel function.

Choice D reason:
Giving the client soda crackers is an important action, as it can provide a bland and easily digestible food for the client. However, this is not the first action the nurse should take, as it may be too solid for the client's stomach if her bowel function has not returned.

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Correct Answer is A

Explanation

Expressions of excitement are typical during the dependent, taking-in phase, which lasts for the first 24 to 48 hr after delivery. The client may relive and review her labor and delivery experience, and may need reassurance and validation from others.

Choice B reason:

Lack of appetite is not an expected finding during the dependent, taking-in phase, as the client may have increased hunger and thirst after delivery. The nurse should encourage adequate nutrition and hydration to promote healing and lactation.

Choice C reason:

Eagerness to learn newborn care skills is more characteristic of the dependent-independent, taking-hold phase, which begins around the third day postpartum. During this phase, the client becomes more confident and interested in caring for herself and her newborn.

ChoiceD reason:

Focus on the family unit and its members is more characteristic of the interdependent, letting-go phase, which occurs after the first week postpartum. During this phase, the client redefines her role within the family and society, and integrates the newborn into her life.

A. Check the consistency of the client's uterine fundus. B. Have the client use the bedpan to urinate. C. Increase the client's ﬂuid intake. D. Prepare to administer oxytocic medication.

Correct Answer is A

Explanation

Choice A reason:

Checking the consistency of the client's uterine fundus is the first action the nurse should take, as it can indicate the cause of excessive bleeding. A boggy or soft fundus indicates uterine atony, which is the most common cause of postpartum hemorrhage. The nurse should massage the fundus until it becomes firm and contracted.

Choice B reason:

Having the client use the bedpan to urinate is an important action, as a full bladder can displace the uterus and prevent it from contracting properly. However, this is not the first action the nurse should take, as it does not address the immediate source of bleeding.

Choice C reason:

Increasing the client's ﬂuid intake is an important action, as it can help replace ﬂuid loss and prevent hypovolemia and shock. However, this is not the first action the nurse should take, as it does not stop the bleeding.

Choice D reason:

Preparing to administer oxytocic medication is an important action, as it can stimulate uterine contractions and reduce bleeding. However, this is not the first action the nurse should take, as it requires a provider's prescription and may not be necessary if fundal massage is eﬀective.

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A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

Correct Answer is A

Explanation

A nurse is caring for a client 2 hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

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