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 C
Explanation
A) Incorrect- Checking urine for ketones is not necessary if the newborn's blood glucose level is low but stable and the baby is asymptomatic.
B) Incorrect- Administering glucagon is not indicated for an asymptomatic newborn with a low but stable blood glucose level.
C) Correct - Encouraging additional feeding is appropriate for an asymptomatic newborn with a low blood glucose level. Regular feeding can help increase blood glucose levels.
D) Incorrect- Waiting 4 hours to recheck blood glucose might not be appropriate if the baby's blood glucose is currently low. Addressing the low blood glucose level is more immediate.
Correct Answer is C
Explanation
A) Incorrect- Oxytocin is not typically administered during a nonstress test.
B) Incorrect- A nonstress test is used to assess fetal well-being and does not indicate Down syndrome.
C) Correct - A lateral tilt position (usually left lateral tilt) is recommended during a nonstress test to prevent compression of the vena cava and maintain proper blood flow to the uterus, which can optimize fetal heart rate monitoring.
D) Incorrect- NPO status is not typically required for a nonstress test. Nonstress tests are non-invasive and do not involve fasting.
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