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

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

A. Umbilical area B. Suprapubic area C. Above the left iliac crest D. Below the liver border on the right abdomen

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.

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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 assisting with the care of a newborn whose mother has hepatitis B. Which of the following actions should the nurse plan to take when administering the hepatitis B vaccine?

Correct Answer is C

Explanation

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

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