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?
Monitor perineal pads for clots.
Assist the client to empty her bladder.
Notify the provider.
Administer a prescribed analgesic.
The Correct Answer is B
Choice A rationale
"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.
Choice B rationale
"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.
Choice C rationale
"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.
Choice D rationale
"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Positioning the newborn's car seat at a 45° angle helps to maintain an open airway and reduces the risk of the baby's head falling forward, which can obstruct breathing.
Choice B rationale
Placing the car seat in a forward-facing position is incorrect for a newborn. Newborns and infants should always be placed in a rear-facing car seat to protect their head, neck, and spine in the event of a crash.
Choice C rationale
Placing a rolled blanket behind the newborn's neck is not recommended as it can alter the position of the head and neck, potentially compromising the airway. Proper positioning is crucial to ensure safety and comfort.
Choice D rationale
The retainer clip should be positioned at the level of the newborn's armpits, not the umbilicus. Proper placement of the retainer clip ensures that the harness is secure and reduces the risk of injury in a collision.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Deep-vein thrombosis is not a contraindication for using a diaphragm. The diaphragm does not affect blood clotting mechanisms.
Choice B rationale: Tobacco use is a risk factor for cardiovascular disease but is not a contraindication for diaphragm use.
Choice C rationale: Recurrent urinary tract infections are a contraindication for diaphragm use. The diaphragm can increase the risk of urinary tract infections due to its placement and the need for spermicide, which can disrupt the natural flora of the vagina.
Choice D rationale: A history of positive group B streptococcus B-hemolytic is not a contraindication for diaphragm use. Group B strep colonization is managed with antibiotics during labor, not by contraceptive choice.
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