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 D
Explanation
“You should place your baby on her back when sleeping to decrease the risk of SIDS.” According to Mayo Clinic, placing a baby on their back to sleep is one of the most important measures that can be taken to help protect a child from SIDS1.
Choice A is incorrect because there is no evidence that SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines.
Choice B is incorrect because SIDS rates have actually decreased dramatically since the American Academy of Pediatrics issued its safe sleep recommendations in 19922.
Choice C is incorrect because while sleep apnea may contribute to breathing problems, it is not considered the main cause of SIDS1.
Correct Answer is B
Explanation
This is known as the Adams Forward Bend Test and is a standard screening test for scoliosis.
Choice A is incorrect because touching the chin to the chest and looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening.
Choice C is incorrect because turning to the side and remaining relaxed does not provide a view of the spine necessary for scoliosis screening.
Choice D is incorrect because lying prone on the examination table does not provide a view of the spine necessary for scoliosis screening.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.