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 B
Explanation
The correct answer is choiceB. Expressions of excitement.
Choice A rationale:
Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase, which follows the “taking-in” phase.During the taking-hold phase, the mother becomes more independent and starts to take an active role in caring for her newborn.
Choice B rationale:
Expressions of excitement are typical during the “taking-in” phase. This phase occurs in the first 1-2 days postpartum, where the mother is primarily focused on herself and her birth experience.She may be excited and talkative about the birth process.
Choice C rationale:
Focus on the family unit and its members is more aligned with the “letting-go” phase, which is the final phase of maternal postpartum adjustment.In this phase, the mother starts to integrate the newborn into the family and adjusts to her new role.
Choice D rationale:
Lack of appetite can occur during the “taking-in” phase due to exhaustion and the physical demands of labor, but it is not a defining characteristic of this phase.
Correct Answer is D
Explanation
Choice A rationale
Thrombophlebitis is a condition where a blood clot in a vein causes inflammation and pain. While it can occur postpartum, it is not directly related to the weight of the newborn.
Choice B rationale
Retained placental fragments can occur after childbirth and can lead to postpartum hemorrhage or infection. However, this complication is not directly related to the weight of the newborn.
Choice C rationale
Puerperal infection, also known as postpartum infection, can occur after childbirth. However, it is not directly related to the weight of the newborn.
Choice D rationale
Uterine atony, a condition where the uterus fails to contract after the delivery of the baby, is a common cause of postpartum hemorrhage. A larger newborn, such as one weighing 9 lb 6 oz, can overstretch the uterus, increasing the risk of uterine atony.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.