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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:

Stop breastfeeding. This is the correct answer because newborns and infants with galactosemia cannot metabolize galactose, a sugar found in milk and lactose-containing formulas, including breast milk. Galactose can build up in their blood and cause serious complications such as liver damage, cataracts, brain damage, and even death. Therefore, the therapeutic management for this newborn is to stop breastfeeding and switch to a soy or elemental formula that contains no galactose.

Choice B reason:

Add amino acids to the breast milk. This is incorrect because adding amino acids to breast milk will not prevent the accumulation of galactose in the newborn's blood. Amino acids are the building blocks of proteins, not sugars. Adding amino acids to breast milk will not change its galactose content or help the newborn metabolize it.

Choice C reason:

Substitute a lactose-containing formula for breast milk. This is incorrect because lactose is a disaccharide composed of glucose and galactose. Lactose-containing formulas will also expose the newborn to galactose, which they cannot break down. Lactose-containing formulas should be avoided in newborns and infants with galactosemia.

Choice D reason:

Give the appropriate enzyme along with breast milk. This is incorrect because there is no enzyme therapy available for galactosemia. Galactosemia is caused by a genetic defect in one of the enzymes involved in the breakdown of galactose, such as galactose-1-phosphate uridyltransferase (GALT), galactokinase (GALK), or uridine diphosphate galactose-4-epimerase (GALE). Giving an enzyme along with breast milk will not correct this defect or prevent the harmful effects of galactose accumulation.

A. Slow growth. B. Fatigue. C. Hematoma. D. Pruritus.

Correct Answer is ["A","B"]

Explanation

Choice A reason:

Slow growth is a common symptom of thalassemia, especially in children. It is caused by the reduced production of hemoglobin and red blood cells, which leads to anemia and poor oxygen delivery to the tissues. Slow growth can also affect the development of facial bones and cause deformities.

Choice B reason:

Fatigue is another common symptom of thalassemia, also related to anemia and low oxygen levels in the body. People with thalassemia may feel tired, weak, and short of breath even after mild physical activity. Fatigue can also affect their mood, concentration, and quality of life.

Choice C reason:

Hematoma is not a typical symptom of thalassemia. Hematoma is a collection of blood under the skin or in an organ, usually caused by trauma, injury, or bleeding disorders. People with thalassemia may have a higher risk of bleeding due to low platelet counts or frequent blood transfusions, but this does not necessarily result in hematoma.

Choice D reason:

Pruritus is not a typical symptom of thalassemia. Pruritus is a sensation of itching that can affect any part of the body. It can have many causes, such as dry skin, allergies, infections, or liver problems. People with thalassemia may experience pruritus as a side effect of iron overload or iron chelation therapy, but it is not a direct consequence of the condition.

Choice E reason:

Ecchymoses are not typical symptoms of thalassemia. Ecchymoses are large bruises that appear on the skin due to bleeding under the surface. They can be caused by trauma, injury, or bleeding disorders. People with thalassemia may have a higher risk of bleeding due to low platelet counts or frequent blood transfusions, but this does not necessarily result in ecchymoses.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A breastfed newborn has just been diagnosed with galactosemia. The therapeutic management for this newborn is to:

Correct Answer is A

Explanation

What are the signs and symptoms of Thalassemia? Select all that apply.

Correct Answer is ["A","B"]

Explanation

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