A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?

Encourage the client to nurse more frequently so her milk will come in

Report the client's temperature elevation

Ask the client to empty her bladder

Increase IV fluids

Answer and Explanation

The Correct Answer is C

ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.

Choice A is not correct because the client's milk will come in regardless of nursing frequency.

Choice B is not correct because the client's temperature is within normal limits.

Choice D is not correct because there is no indication of an increase in IV fluids.

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Correct Answer is C

Explanation

Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.

Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.

Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.

Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.

A. Administer oxytocin. B. Observe for pooling of blood under the buttocks. C. Check the client's blood pressure. D. Massage the client's fundus.

Correct Answer is D

Explanation

Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.

Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

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A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

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Naxlex Comprehensive Predictor Exams

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Correct Answer is C

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min.
Which of the following actions should the nurse perform?