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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A:
Lidocaine gel to the umbilical stump is not a medication that the nurse should expect to administer to a newborn immediately following birth. Lidocaine gel is a topical anesthetic that is used to numb the skin before procedures such as injections or sutures. It is not indicated for the umbilical stump, which does not require any anesthesia.
Choice B:
Hepatitis B immunization is a medication that the nurse should expect to administer to a newborn immediately following birth. Hepatitis B is a viral infection that can cause liver damage and cancer. The immunization protects the newborn from contracting the infection from the mother or other sources. The immunization is given as an intramuscular injection in the anterolateral thigh within 12 hours of birth.
Choice C:
Phytonadione injection is a medication that the nurse should expect to administer to a newborn immediately following birth. Phytonadione is also known as vitamin K, which is essential for blood clotting. Newborns have low levels of vitamin K at birth, which puts them at risk of bleeding disorders such as hemorrhagic disease of the newborn. The injection is given as a single dose of 0.5 to 1 mg in the vastus lateralis muscle within 1 hour of birth.
Choice D:
Antibiotic ophthalmic ointment is a medication that the nurse should expect to administer to a newborn immediately following birth. Antibiotic ophthalmic ointment prevents eye infections caused by bacteria such as gonorrhea or chlamydia, which can be transmitted from the mother during delivery. The ointment is applied to both eyes within 1 hour of birth.
Choice E:
Haemophilus influenzae type b vaccine (Hib) is not a medication that the nurse should expect to administer to a newborn immediately following birth. Hib is a bacterial infection that can cause meningitis, pneumonia, and other serious illnesses. The vaccine protects the newborn from Hib infection, but it is not given at birth. The vaccine is part of the routine immunization schedule and is usually given at 2, 4, and 6 months of age.
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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