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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

An ectopic pregnancy, where the fertilized egg attaches outside the uterus, often presents with unilateral, cramp-like abdominal pain. This is because as the fertilized egg grows in an area where it cannot survive, it can cause irritation and bleeding, leading to pain. This pain is often one-sided or unilateral and can vary from mild to severe. It’s one of the key symptoms that can suggest an ectopic pregnancy in the early weeks of gestation.

Choice B rationale

Severe nausea and vomiting are not typically the primary symptoms associated with an ectopic pregnancy. While nausea can be a symptom of early pregnancy, severe nausea and vomiting alone without other symptoms would not necessarily indicate an ectopic pregnancy.

Choice C rationale

Uterine enlargement greater than expected for gestational age is not a symptom of an ectopic pregnancy. In fact, because the pregnancy is not in the uterus, the size of the uterus may not correlate with the expected size at the given gestational age.

Choice D rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is not typically a large amount. The bleeding is often lighter than normal menstrual bleeding and may be associated with a change in color of the vaginal discharge.

A. Turn the client onto her side. B. Increase the client’s IV fluid infusion rate. C. Palpate the client’s uterus. D. Administer oxygen to the client.

Correct Answer is A

Explanation

Choice A rationale

Turning the client onto her side is the first action the nurse should take when late decelerations are noted on the fetal monitor. Late decelerations can indicate uteroplacental insufficiency, and turning the client onto her side can improve placental blood flow and oxygen delivery to the fetus.

Choice B rationale

Increasing the client’s IV fluid infusion rate can help increase maternal blood volume and improve placental perfusion. However, it is not the first action to take when late decelerations are noted.

Choice C rationale

Palpating the client’s uterus can provide information about the strength, duration, and frequency of contractions, but it is not the first action to take when late decelerations are noted.

Choice D rationale

Administering oxygen to the client can increase the amount of available oxygen for fetal oxygenation. However, it is not the first action to take when late decelerations are noted.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is suspected to have an ectopic pregnancy at 8 weeks of gestation. What symptoms should the nurse expect to observe that are consistent with this diagnosis?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who is in active labor when the client’s membranes rupture. The fetal monitor tracing shows late decelerations. What is the first action the nurse should take?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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?