A nurse is caring for a client who had a vaginal delivery 2 hours ago.
Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
Observe the lochia during palpation of the fundus.
Massage a firm fundus.
Determine whether the fundus is midline.
Document fundal height.
Administer methylergonovine maleate.
Correct Answer : A,C,E
Step 1: The nurse should observe the lochia during palpation of the fundus. This can help assess the amount and type of vaginal discharge after childbirth.
Step 2: The nurse should not massage a firm fundus. If the uterus is firm, it means it is contracting well to control bleeding.
Step 3: The nurse should determine whether the fundus is midline. A uterus that is not midline may indicate a full bladder, which can interfere with uterine contraction and lead to increased bleeding.
Step 4: Documenting fundal height is not typically done postpartum. Instead, the nurse assesses whether the fundus is firm and midline.
Step 5: The nurse should administer methylergonovine maleate if the uterus is boggy. This medication helps the uterus contract to control bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This is the correct answer. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.
Choice B rationale
Rupture of the membranes can occur before or during labor, but it is not a definitive sign of true labor.
Choice C rationale
The position of the presenting part is not a definitive sign of true labor.
Choice D rationale
Changes in the cervix can be a sign of true labor, but without regular, strong contractions, it is not a definitive sign.
Correct Answer is A
Explanation
The correct answer is choice A. Drink 48 to 64 ounces of water daily.
Choice A rationale:
Drinking 48 to 64 ounces of water daily is recommended to help maintain hydration and support overall health during pregnancy, especially for those with mild preeclampsia.
Choice B rationale:
While protein intake is important, the recommended amount for pregnant women is generally higher than 40 to 90 grams per day. The exact amount can vary based on individual needs, but typically, pregnant women are advised to consume around 71 grams of protein daily.
Choice C rationale:
Limiting intake of whole grains, raw fruits, and vegetables is not recommended. These foods are rich in essential nutrients and fiber, which are beneficial for both the mother and the baby.
Choice D rationale:
Avoiding salting of foods during cooking can help manage blood pressure, but it is not the primary focus of dietary recommendations for preeclampsia. Reducing overall sodium intake is more important.
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