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

Answer and Explanation

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 D

Explanation

Choice A reason:
Telling a client that a pelvic exam is required for birth control pills is not accurate. Current medical guidelines indicate that a pelvic exam is not necessary to prescribe oral contraceptive medications, hormonal contraceptives can be safely prescribed based on medical history and blood pressure measurement without the need for a pelvic or breast examination.

Choice B reason:
While offering support is important, simply telling the client not to worry does not address her specific concerns or provide her with information about the process and her options.

Choice C reason:
Advising the client to relax does not acknowledge the validity of her feelings or provide her with any concrete information or support to help alleviate her anxiety.

Choice D reason:
Asking the client what part of the exam makes her most nervous is an open-ended question that invites dialogue. It allows the nurse to provide targeted information and reassurance, addressing the client's specific concerns and promoting a sense of control and participation in her own health care decisions.

A. Encourage the client to move to the left lateral position. B. Ask the client to rate her pain. C. Assist the client to the bathroom to void. D. Encourage the client to perform Kegel exercises.

Correct Answer is C

Explanation

Choice a Reason: Encourage the client to move to the left lateral position

Moving to the left lateral position is often recommended to improve circulation and prevent compression of the vena cava by the uterus in a pregnant client. However, in the case of a boggy fundus postpartum, this position is not the primary action to be taken.

Choice b Reason: Ask the client to rate her pain

While assessing pain is important in the postpartum period, it is not the immediate action required for a boggy fundus. A boggy fundus indicates that the uterus is not contracting properly, which can lead to excessive bleeding.

Choice c Reason: Assist the client to the bathroom to void

A boggy fundus that is displaced to the right often indicates a full bladder, which can prevent the uterus from contracting effectively. Assisting the client to the bathroom to void can help the uterus contract and reduce the risk of hemorrhage.

Choice d Reason: Encourage the client to perform Kegel exercises

Kegel exercises are beneficial for strengthening the pelvic floor muscles after childbirth. However, they are not the immediate action to take for a boggy fundus postpartum

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

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