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 D
Explanation
Choice A reason:
Obesity is not a common complication of phenylketonuria (PKU), a genetic disorder that causes increased levels of phenylalanine (an amino acid) in the body. Obesity may be related to other endocrine disorders, such as hypothyroidism or Cushing syndrome.
Choice B reason:
Diabetes insipidus is a condition that causes excessive thirst and urination due to a lack of antidiuretic hormone (ADH) or a problem with the kidneys' response to ADH. It is not caused by PKU, which affects the metabolism of phenylalanine.
Choice C reason:
Respiratory distress is not a typical symptom of PKU, although some newborns with PKU may have a musty odor in their breath, skin, or urine due to the buildup of phenylalanine.
Respiratory distress may be caused by other conditions, such as asthma, pneumonia, or congenital heart defects.
Choice D reason:
Cognitive impairment is the most serious complication of PKU if it is not diagnosed and treated early. High levels of phenylalanine can damage the brain and cause irreversible intellectual disability, neurological problems, and behavioral issues. Early intervention with a special diet that limits phenylalanine intake can prevent or reduce cognitive impairment in children with PKU.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:
Preterm birth is a major risk factor for neonatal sepsis, especially early-onset sepsis. Preterm babies have immature immune systems and lack antibodies to protect them against certain bacteria.
Choice B reason:
Cesarean birth is not a risk factor for neonatal sepsis by itself, unless it is associated with other factors such as prolonged rupture of membranes, maternal infection or chorioamnionitis.
Choice C reason:
Precipitous delivery is a risk factor for neonatal sepsis, especially early-onset sepsis. Precipitous delivery can cause fetal distress, hypoxia, acidosis and increased susceptibility to infection.
Choice D reason:
Frequent vaginal exams are a risk factor for neonatal sepsis, especially early-onset sepsis. Frequent vaginal exams can introduce bacteria into the amniotic fluid and increase the risk of ascending infection.
Choice E reason:
Mother has GBS infection is a risk factor for neonatal sepsis, especially early-onset sepsis. GBS (group B streptococcus) is the most common cause of early-onset neonatal sepsis and can be transmitted from the mother to the baby during labor and delivery.
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