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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Insulin is the most commonly used medication for managing gestational diabetes because it does not cross the placenta and is considered safe for both the mother and the fetus. Other oral antidiabetic medications like repaglinide, glipizide, and acarbose are generally not recommended during pregnancy due to concerns about their safety for the fetus.
Correct Answer is D
Explanation
A Covering the umbilical cord stump with the diaper can create a moist environment, which may increase the risk of bacterial growth and infection.
B. Washing the cord stump with soap and water may disrupt the natural drying process and increase the risk of infection
C. Applying petroleum jelly or any other substance to the umbilical cord stump is not necessary and may increase the risk of infection.
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