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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Foul-smelling vaginal discharge might indicate infection but is not the priority over the presence of meconium-stained amniotic fluid.
B) Correct- Fetal heart rate is important to monitor, but the presence of meconium- stained amniotic fluid has higher priority. fetal heart tones 98/min, because this indicates fetal distress and requires immediate intervention.
C) Incorrect - Amniotic fluid with meconium noted could indicate fetal hypoxia or distress, but it is not always a sign of a problem and depends on other factors such as gestational age and fetal activity.
D) Incorrect- Maternal temperature elevation might indicate infection but is not the priority over assessing the condition of the amniotic fluid and the baby.
Correct Answer is C
Explanation
A) Incorrect- Elevated blood pressure is not a primary risk associated with hyperemesis gravidarum.
B) Incorrect- Leukopenia (low white blood cell count) is not a common consequence of hyperemesis gravidarum.
C) Correct - Hyperemesis gravidarum, severe nausea, and vomiting during pregnancy can lead to dehydration, which may affect amniotic fluid levels and result in hydramnios (excessive amniotic fluid).
D) Incorrect- Ketonuria (presence of ketones in the urine) is a possible consequence of excessive vomiting, but it's not the primary concern associated with hyperemesis gravidarum.
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