A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

Insert a urinary catheter.

Massage the fundus.

Have the client urinate.

Administer an analgesic

Answer and Explanation

The Correct Answer is C

A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client

urinate voluntarily. Administering an analgesic is not indicated based on the information provided.

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Correct Answer is C

Explanation

This action is important as it helps to prevent hypothermia, which newborns are particularly susceptible to. However, while drying the infant is essential, it should not be the very first action taken immediately after birth.

Stimulating the infant to cry can help establish normal respiratory function and is important for transitioning to extrauterine life. However, it may not be the first action if the infant is not breathing or appears to need immediate airway clearance.

This is a critical first step, especially if the newborn is not breathing adequately. Clearing the airway (using suction if necessary) is vital to ensure that the infant can breathe properly and transition well after birth. If there are any signs of airway obstruction or if the infant is not crying, this action takes precedence.

While cutting the umbilical cord is a standard procedure, it is typically performed after ensuring the infant is stable. Current guidelines suggest delaying cord clamping for a short period unless there are complications that require immediate action.

A. Projectile vomiting after feedings B. Absent bowel sounds C. Increased sodium levels D. Golf ball-sized mass over the left quadrant

Correct Answer is A

Explanation

Rationale

Pyloric stenosis is a condition characterized by narrowing of the pylorus, the opening between the stomach and the small intestine. This narrowing obstructs the passage of food from the stomach to the intestines. This leads to typical projectile postprandial vomiting.

B, C, D are not typical features of pyloric stenosis

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A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is C

Explanation

A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?

Correct Answer is A

Explanation

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