A nurse is caring for a patient who experienced a vaginal birth 3 hours ago.
Upon palpation, the fundus is displaced to the right of the midline, is firm, and is two fingerbreadths above the umbilicus.
What actions should the nurse complete at this time?
Insert a urinary catheter.
Massage the fundus.
Have the patient urinate.
Administer an analgesic.
The Correct Answer is C
Choice A rationale
Inserting a urinary catheter is not typically the first action when the fundus is displaced. It is more commonly done when the bladder is distended and the patient is unable to urinate.
Choice B rationale
Massaging the fundus is usually done when the uterus is soft or boggy to help it contract and prevent postpartum hemorrhage. However, in this case, the fundus is firm, indicating that the uterus is well contracted.
Choice C rationale
Having the patient urinate is the appropriate action when the fundus is displaced to the right of the midline. This displacement often indicates a full bladder, which can push the uterus to the side. After the patient urinates, the uterus often returns to the midline position.
Choice D rationale
Administering an analgesic is not the first action when the fundus is displaced. Pain medication is typically given for postpartum discomfort or afterbirth pains, not for a displaced fundus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Swaddling a newborn can provide comfort and help soothe them. However, it is not a specific treatment for a Neonatal Abstinence Scoring System (NAS) score of 201.
Choice B rationale
Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. It is not typically administered for NAS unless the newborn is experiencing life-threatening respiratory depression due to opioid exposure. Moreover, it is not specifically indicated for NAS scores greater than 241.
Choice C rationale
Continuing NAS scoring as prescribed is important for monitoring the newborn’s condition. However, a score of 20 indicates significant withdrawal symptoms, which may require more than just monitoring.
Choice D rationale
Administering oral morphine is a common treatment for NAS. Morphine, an opioid medication, is used to manage withdrawal symptoms in newborns with NAS. The goal is to control symptoms and then gradually wean the newborn off the medication.
Correct Answer is D
Explanation
Choice A rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. While NAS can pose risks to a newborn, it is not considered the greatest risk.
Choice B rationale
Developmental Dysplasia of the Hip (DDH) is a condition where the “ball and socket” joint of the hip does not properly form in babies and young children. While DDH can pose risks to a newborn, it is not considered the greatest risk.
Choice C rationale
Subgaleal hemorrhage is a rare but potentially lethal condition in newborns, usually resulting from vacuum-assisted delivery. While it can pose risks to a newborn, it is not considered the greatest risk.
Choice D rationale
Congenital cardiac defects are the most common type of birth defect. They can alter the way blood flows through the heart and pose a significant risk to a newborn.
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.