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
Explanation
Choice A reason:
Heat facilitates the drainage of mucus for a premature newborn. This is incorrect because heat does not affect mucus drainage. Mucus drainage is more related to suctioning and hydration.
Choice B reason:
The newborn has a small body surface for his weight. This is incorrect because a small body surface area for weight would indicate a large newborn, not a premature one. A large newborn would have less risk of heat loss than a small one.
Choice C reason:
The newborn's temperature control mechanism is immature. This is correct because premature newborns have immature thermoregulation and are prone to hypothermia. Placing the newborn in an incubator helps maintain a stable temperature and prevent further complications.
Choice D reason:
Heat increases the flow of oxygen to the newborn's extremities. This is incorrect because heat does not directly affect oxygen delivery. Oxygen delivery is more related to ventilation, perfusion, and hemoglobin levels. The question is about a premature newborn who has signs of respiratory distress, such as nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. These signs indicate that the newborn is having difficulty breathing and may have a condition such as respiratory distress syndrome, transient tachypnea of the newborn, or meconium aspiration syndrome. The nurse should place the newborn in an incubator to provide warmth and prevent heat loss, which can worsen respiratory distress. The nurse should also monitor the newborn's vital signs, oxygen saturation, blood gases, chest x-ray, and neonatal abstinence scoring system if indicated. The nurse should be prepared to administer oxygen, surfactant, or mechanical ventilation as ordered.
Correct Answer is A
Explanation
Choice A reason:
Smoking is the most significant risk factor for clubfoot, according to several studies that have found a strong association between maternal smoking during pregnancy and the occurrence of clubfoot in the offspring. Smoking may affect the development of the muscles and tendons in the fetus, leading to abnormal positioning of the foot.
Choice B reason:
Trauma during pregnancy is not a significant risk factor for clubfoot, as there is no evidence that physical injury to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Choice C reason:
Hypertension is not a significant risk factor for clubfoot, as there is no evidence that high blood pressure in the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Choice D reason:
Decreased circulation is not a significant risk factor for clubfoot, as there is no evidence that poor blood flow to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
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