A nurse is collecting data from a client who is 14 hr postpartum.
The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F); pulse rate 88/min; respiratory rate 18/min.
Which of the following actions should the nurse perform?
Report the client's temperature elevation.
Encourage the client to nurse more frequently so her milk will come in.
Ask the client to empty her bladder.
Increase IV fluids.
The Correct Answer is C
A full bladder can displace the uterus and cause it to deviate to one side.
Choice A is not correct because a temperature of 37.7° C (100° F) is within the normal range for a postpartum client.
Choice B is not correct because the client’s milk production is not related to the findings noted by the nurse.
Choice D is not correct because there is no indication that the client needs an increase in IV fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should teach the patient to report promptly any edema of the face and hands.
Edema of the face and hands can be a sign of preeclampsia, a serious pregnancy complication that can lead to high blood pressure and damage to organs such as the liver and kidneys.
Preeclampsia can be dangerous for both the mother and the baby and requires prompt medical attention.
Choice A is not an answer because nasal congestion is a common symptom during pregnancy and is not considered a danger sign.
Choice C is not an answer because hemorrhoids are also a common symptom during pregnancy and are not considered a danger sign.
Choice D is not an answer because varicose veins are also a common symptom during pregnancy and are not considered a danger sign.
Correct Answer is C
Explanation
This question is important because it helps the nurse assess the level of risk and determine the appropriate intervention.
It is important to take all threats, communications, and suggestions regarding suicide seriously.
Choice A is not correct because it focuses on past events rather than the current situation.
Choice B is not correct because it may come across as confrontational and may not be helpful in assessing the level of risk.
Choice D is not correct because it focuses on the reason for feeling depressed rather than assessing the level of risk and determining appropriate intervention.
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