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 A
Explanation
The umbilical vein carries oxygen-rich blood to the fetus from the placenta.
The umbilical vein is an important part of fetal circulation and carries oxygenated blood from the placenta into the growing fetus.
Choice B is incorrect because the two umbilical arteries carry deoxygenated blood from the fetus to the placenta23.
Choice C is incorrect because there are not two umbilical veins, but only one12.
Choice D is incorrect because it is not the one umbilical artery that carries oxygen-rich blood to the fetus from the placenta, but rather the one umbilical vein14.
Correct Answer is D
Explanation
During the first trimester of pregnancy, many women experience increased urination.
The amount of blood in your body increases during pregnancy, causing your kidneys to process extra fluid that ends up in your bladder.
Choice A, Supine hypotension, is incorrect because it refers to a condition that can occur later in pregnancy when a woman lies on her back and the weight of the uterus compresses major blood vessels.
Choice B, Heartburn, is incorrect because it is more commonly experienced later in pregnancy.
Choice C, Constipation, is incorrect because it is more commonly experienced later in pregnancy.
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