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
This finding indicates fetal distress. Recurrent variable decelerations in the fetal heart rate (FHR) can be a sign of umbilical cord compression, which can compromise fetal oxygenation.
Choice B rationale
Uterine contractions every 6 minutes are within the normal range for the latent phase of labor and do not indicate fetal risk.
Choice C rationale
Moderate variability of the FHR is a reassuring sign and suggests that the fetus is well-oxygenated and neurologically intact.
Choice D rationale
Uterine contractions lasting 30 to 45 seconds are typical for the latent phase of labor and do not indicate fetal distress.
Correct Answer is A
Explanation
Choice A rationale
"You will be tested again for GBS at about 36 weeks of gestation.”. This is correct because retesting for GBS at 35-37 weeks of gestation is standard practice to identify colonization status before delivery, which helps in planning intrapartum antibiotic prophylaxis.
Choice B rationale
"If you test positive for GBS, the provider will need to perform a cesarean birth.”. This is incorrect because GBS colonization is not an indication for cesarean delivery. The primary intervention is antibiotic administration during labor to prevent neonatal infection.
Choice C rationale
"You will take an antibiotic during the last 2 weeks of pregnancy to avoid transferring GBS to your baby.”. This is incorrect because antibiotics are given intrapartum (during labor) to prevent GBS transmission, not during the last weeks of pregnancy.
Choice D rationale
"This infection can cause your baby to experience hearing loss at birth.”. This is incorrect because GBS infection primarily causes sepsis, pneumonia, and meningitis in neonates, not hearing loss.
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