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
Deep tendon reflexes of +1 are not consistent with preeclampsia. Preeclampsia is often associated with hyperreflexia, which would be a deep tendon reflex of +3 or +467.
Choice B rationale
3+ protein in the urine is consistent with preeclampsia. Proteinuria is a common finding in preeclampsia due to kidney involvement.
Choice C rationale
Blood pressure 148/98 mm Hg is consistent with preeclampsia. Hypertension is a key feature of preeclampsia.
Choice D rationale
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the face and hands, is a common finding in preeclampsia.
Correct Answer is A
Explanation
Choice A rationale
The priority action by the nurse following an amniotomy is to assess the fetal heart rate. This is because changes in the fetal heart rate can indicate fetal distress, which could be caused by cord compression or other complications related to the amniotomy.
Choice B rationale
While assessing the odor of the amniotic fluid is important to identify possible infections, it is not the priority action following an amniotomy.
Choice C rationale
Providing clean, dry underpads is part of standard care following an amniotomy, but it is not the priority action.
Choice D rationale
Monitoring the client’s temperature is important to identify possible infection, but it is not the priority action immediately following an amniotomy.
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