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
Blood volume increases significantly within the first few weeks of gestation and increases progressively throughout the pregnancy.
The total blood volume increase varies from 20% to 100% above prepregnancy levels, usually close to 45%1.
Choice A is incorrect because the increase is usually close to 45%, not 20% to 25%.
Choice C is incorrect because the increase is usually close to 45%, not 50% to 55%.
Choice D is incorrect because the increase is usually close to 45%, not 30% to 35%.
Correct Answer is B
Explanation
The nurse observes Brittny during meal times and for 2 hours after eating to monitor for purging behaviors.
Choice A is incorrect because building a trusting relationship with the patient is important but not the primary reason for observing the patient during meal times and for 2 hours after eating.
Choice C is incorrect because teaching about nutrition is important but not the primary reason for observing the patient during meal times and for 2 hours after eating.
Choice D is incorrect because taking a break with the patient is not the primary reason for observing the patient during meal times and for 2 hours after eating.
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