A nurse is caring for a client who is 14 hours postpartum.
The nurse notes that the client’s breasts are soft, the fundus is firm and slightly deviated to the right, and the client’s
pulse rate is 88/min with a respiratory rate of 18/min.
Which of the following actions should the nurse take?
Ask the client to empty her bladder
Repeat the client’s temperature evaluation
Encourage the client to nurse more frequently
Check for signs of a urinary tract infection
The Correct Answer is A
Choice A rationale:
A full bladder can displace the uterus to the right and interfere with its ability to contract properly. This can lead to
postpartum hemorrhage, a serious complication that can occur after childbirth.
Emptying the bladder helps to reposition the uterus in the midline and allows it to contract more effectively. This helps to
prevent postpartum hemorrhage and promotes uterine involution, the process by which the uterus returns to its pre-
pregnancy size.
In this case, the client's fundus is firm, which indicates that it is contracting well. However, it is slightly deviated to the right,
which suggests that the bladder may be full.
Asking the client to empty her bladder is a simple and effective way to address this potential problem.
Choice B rationale:
Repeating the client's temperature evaluation is not a priority action in this case. The client's vital signs are within normal
limits, and there is no indication of infection.
A temperature elevation could be a sign of infection, but it is not the most likely cause of the uterine deviation in this case.
Choice C rationale:
Encouraging the client to nurse more frequently may be helpful in stimulating milk production and uterine contractions.
However, it is not the most immediate priority in this case.
The client's breasts are soft, which suggests that she is not yet producing a significant amount of milk.
The priority is to address the potential problem of a full bladder, which could interfere with uterine involution.
Choice D rationale:
Checking for signs of a urinary tract infection is not a priority action in this case. The client does not have any urinary
symptoms, such as dysuria or frequency.
A urinary tract infection could cause a uterine deviation, but it is not the most likely cause in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Checking the client’s blood pressure is important, but it is not the first action the nurse should take. Hypotension could
indicate hemorrhage, but the nurse needs to address the immediate risk of excessive bleeding.
Choice B rationale:
The nurse should first massage the client’s fundus. A saturated perineal pad could indicate a postpartum hemorrhage.
Massaging the fundus helps the uterus contract and may stop the bleeding.
Choice C rationale:
Observing for pooling of blood under the buttocks is a way to assess for bleeding. However, this is not the first action because
it does not address the cause of the bleeding.
Choice D rationale:
Administering oxytocin can help the uterus contract and reduce bleeding. However, this is not the first action because it
requires a physician’s order.
Correct Answer is B
Explanation
Choice A rationale:
Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.
Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.
Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.
Choice D rationale:
Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after
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.