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
During pregnancy, a woman needs to increase her caloric intake by approximately 300 extra calories per day.
These extra calories should come from a balanced diet of protein, fruits, vegetables, and whole grains.
Choice A is incorrect because adding an additional 500 calories/day by drinking milkshakes is not a healthy way to increase caloric intake during pregnancy.
Choice C is incorrect because doubling caloric intake is not necessary during pregnancy.
Choice D is incorrect because while it is important to watch caloric intake during pregnancy, it is also important to increase caloric intake by approximately 300 extra calories per day.
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