A nurse is caring for a client who is postpartum and has received methylergonovine. Which of the following findings indicates that the medication was effective?
Fundus firm to palpation
Report of absent breast pain
Increase in lochia
Increase in blood pressure
The Correct Answer is A
Choice A reason:
Methylergonovine is used postpartum to prevent or control uterine bleeding by causing the uterus to contract. A firm fundus upon palpation indicates that the uterus is contracting well, which helps to compress the blood vessels and prevent excessive bleeding. This is the expected outcome when methylergonovine is effective.
Choice B reason:
The absence of breast pain is not directly related to the effectiveness of methylergonovine. Breast pain or engorgement typically occurs when milk comes in a few days postpartum and is not influenced by uterotonic medications.
Choice C reason:
An increase in lochia, or postpartum vaginal discharge, is not an indicator of methylergonovine's effectiveness. Lochia will naturally change and decrease as the postpartum period progresses and is not directly affected by the medication.
Choice D reason:
An increase in blood pressure is not an expected effect of methylergonovine and could indicate a side effect or complication. Methylergonovine can cause hypertension as a side effect, so an increase in blood pressure would warrant further assessment rather than indicating effectiveness.
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Correct Answer is A
Explanation
Choice a reason:
A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, the bladder can become distended due to decreased sensitivity, which may be caused by trauma during delivery or the effects of anesthesia. A distended bladder can push the uterus to the side and prevent it from contracting properly, leading to increased bleeding. It's important for the nurse to encourage the client to void to relieve bladder distension and allow the uterus to contract effectively.
Choice b reason:
Less than 2.5 cm of rubra lochia on the perineal pad does not necessarily indicate bladder distension. Lochia rubra is the normal discharge of blood, mucus, and tissue from the uterus after childbirth, and its amount can vary widely among individuals. While heavy lochia can be a sign of postpartum hemorrhage, it is not directly related to bladder distension.
Choice c reason:
Increased thirst in a postpartum client is not a direct indicator of bladder distension. Thirst can be influenced by various factors, including dehydration from labor, breastfeeding, or hormonal changes. While it's important for a postpartum client to stay hydrated, increased thirst alone does not suggest a distended bladder.
Choice d reason:
Frequent uterine contractions reported by the client are not a sign of bladder distension. These contractions, known as afterpains, are normal and occur as the uterus contracts to return to its pre-pregnancy size. While uncomfortable, they are a sign of the uterus working to expel blood and tissue and do not indicate bladder issues.
Correct Answer is C
Explanation
Choice A Reason:
It is not necessary to avoid food and fluids the day of the procedure unless specifically instructed by the healthcare provider. Amniocentesis does not typically require fasting; however, some facilities may have different protocols.
Choice B Reason:
A bowel prep protocol is not required for an amniocentesis. This procedure is unrelated to the gastrointestinal tract, and bowel preparation is more commonly associated with procedures like colonoscopy.
Choice C Reason:
Emptying the bladder immediately prior to the procedure is important. A full bladder can obstruct the view of the uterus during ultrasound, which is used to guide the amniocentesis needle. Additionally, an empty bladder reduces the risk of accidental puncture during the procedure.
Choice D Reason:
Washing the abdomen with soap and water the morning of the procedure is a good hygiene practice but is not specifically required for amniocentesis. The area will be cleaned with antiseptic by the healthcare provider before the procedure.
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