A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

Notify the provider.

Administer a prescribed analgesic

Assist the client to empty her bladder.

Monitor perineal pads for clots.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- While notifying the provider might be necessary, addressing bladder distention takes precedence in this scenario.
B)   Incorrect- Administering an analgesic might be indicated for pain relief, but addressing bladder distention is the priority.
C)   Correct - Assisting the client to empty her bladder is the first action to take. A full bladder can prevent the uterus from contracting properly and can lead to excessive bleeding.
D)   Incorrect- Monitoring perineal pads for clots is important but not the first action to take when bladder distention is present.

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Correct Answer is C

Explanation

Rationale:

A) Incorrect - The umbilical area is not a typical location for auscultating fetal heart tones.
B) Incorrect - The suprapubic area is not a common location for auscultating fetal heart tones.
C) Correct - At 12 weeks of gestation, the nurse would typically auscultate the fetal heart tones above the left iliac crest, which is in the lower abdomen. This is where the uterus is located at this stage of pregnancy.
D) Incorrect - Auscultating below the liver border on the right abdomen is not a standard practice for fetal heart tone assessment.

A. Teroutaline B. Magnesium sulfate C. Methotrexate D. Calcium gluconate

Correct Answer is C

Explanation

A) Incorrect- Terbutaline is a tocolytic medication used to relax uterine muscles and inhibit contractions, not to treat an ectopic pregnancy.
B) Incorrect- Magnesium sulfate is used to prevent seizures in clients with preeclampsia, not to treat ectopic pregnancies.
C) Correct - Methotrexate is often used to treat unruptured ectopic pregnancies in the early stages by inhibiting the growth of trophoblastic tissue.
D) Incorrect- Calcium gluconate is used to treat magnesium toxicity and other conditions related to calcium imbalance, not to treat ectopic pregnancies.

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A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation. Where should the nurse expect to auscultate the fetal heart tones?

Correct Answer is C

Explanation

A nurse is assisting in the care of a client who is experiencing an unruptured ectopic pregnancy that is at 8 weeks of gestation. Which of the following medications should the nurse expect the provider to prescribe?

Correct Answer is C

Explanation

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