A nurse is collecting data from a client who gave birth 12 hours ago. The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus. Which of the following actions should the nurse take first?
Administer methylergometrine to the client.
Assist the client to void.
Insert an indwelling urinary catheter.
Obtain a stat hemoglobin level.
The Correct Answer is B
Choice A reason:
Administering methylergometrine to the client is not the first action the nurse should take. Methylergometrine is a medication that stimulates uterine contractions and can help reduce postpartum bleeding. However, it can also cause hypertension and should be used with caution in clients with high blood pressure. Furthermore, the nurse should first identify and address the cause of the boggy and deviated fundus before giving any medication.
Choice B reason:
Assisting the client to void is the first action the nurse should take. A full bladder can displace the uterus and prevent it from contracting properly, leading to uterine atony and bleeding.
The nurse should help the client empty her bladder by encouraging her to use the bathroom, providing privacy, running water, or using a bedpan. This can help the uterus return to its normal position and tone.
Choice C reason:
Inserting an indwelling urinary catheter is not the first action the nurse should take. A urinary catheter can be used to drain the bladder if the client is unable to void or has a large amount of residual urine. However, it can also increase the risk of infection and trauma to the urethra
and bladder. The nurse should first try noninvasive methods to help the client void, such as those mentioned in choice B.
Choice D reason:
Obtaining a stat hemoglobin level is not the first action the nurse should take. A hemoglobin level can indicate the extent of blood loss and the need for transfusion or other interventions. However, it is not a priority over restoring uterine tone and preventing further bleeding. The nurse should first assist the client to void and then massage the fundus if it remains boggy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A reason:
A prior vaginal delivery is not a contraindication for VBAC. In fact, it is a positive predictor of success for VBAC, as it indicates that the woman has a proven pelvis and can tolerate labor.
Choice B reason:
The gestation of 42 weeks is not a contraindication for VBAC. However, it is associated with an increased risk of stillbirth while awaiting spontaneous labor, which should be balanced against the risks of induction of labor or elective repeat cesarean.
Choice C reason:
Maternal obesity is a relative contraindication for VBAC. It is associated with a lower success rate of VBAC, a higher risk of uterine rupture, and a higher risk of maternal and neonatal complications. The decision to attempt VBAC in obese women should be made on a case-by-case basis by a senior obstetrician.
Choice D reason:
One prior cesarean delivery is not a contraindication for VBAC. Most women who have had one prior lower segment cesarean delivery are eligible for VBAC, as the risk of uterine rupture is low (0.5%) and the success rate is high (72-75%).
Choice E reason:
A macrosomic fetus is a relative contraindication for VBAC. It is associated with a lower success rate of VBAC, a higher risk of uterine rupture, and a higher risk of shoulder dystocia and birth trauma. The decision to attempt VBAC in women with suspected macrosomia should be made on a case-by-case basis by a senior obstetrician.
Correct Answer is A
Explanation
Choice A reason:
This is a normal WBC for a newborn. According to MedlinePlus, the normal amount of white blood cells (WBCs) found in the bloodstream of a newborn infant is between 4,500 and 10,000 per microliter of blood. The reference ranges for WBC count established by Mayo Medical Laboratories for infants from birth to 2 years are as follows:.
• Birth: 9.0 to 30.0 x 10 9 /L.
• 1 to 7 days: 9.4 to 34.0 x 10 9 /L.
• 8 to 14 days: 5.0 to 21.0 x 10 9 /L.
• 15 days to 1 month: 5.0 to 20.0 x 10 9 /L.
• 2 to 5 months: 5.0 to 15.0 x 10 9 /L. Therefore, a newborn's WBC of 15,000 is within the normal range and does not indicate any problem.
Choice B reason:
You must call the doctor. This is not a correct answer because there is no need to call the doctor for a normal WBC in a newborn. Calling the doctor unnecessarily may cause anxiety and a waste of time and resources.
Choice C reason:
This indicates a severe infection. This is not a correct answer because a WBC of 15,000 does not necessarily indicate a severe infection in a newborn. A high WBC, also called leukocytosis, may be related to infection, but it can also be caused by other factors such as stress, inflammation, trauma, medication, or blood disorders. Moreover, the type and severity of infection can be better assessed by looking at the differential count of the different types of white blood cells (neutrophils, eosinophils, basophils, monocytes, and lymphocytes) and other signs and symptoms.
Choice D reason:
This is a lab error. This is not a correct answer because a WBC of 15,000 is not likely to be a lab error in a newborn. Lab errors can occur due to improper collection, handling, or analysis of blood samples, but they are rare and usually detected by quality control measures. A WBC of 15,000 is within the normal range for a newborn and does not require repeating the test unless there is a strong suspicion of an error or an inconsistency with other results or clinical findings.
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