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
When people with bulimia nervosa frequently engage in self-induced vomiting, the gastric acids in their vomit can damage the tooth enamel.
This is called dental erosion and can create “bulimia teeth”.
Choice A, Food is rapidly ingested without proper mastication, is incorrect because it does not directly relate to tooth enamel deterioration.
Choice C, Poor dental and oral hygiene leads to dental caries, is incorrect because it refers to a different dental issue.
Choice D, Purging causes the depletion of dietary calcium, is incorrect because it does not directly relate to tooth enamel deterioration.
Correct Answer is C
Explanation
By 3 months old, most babies can lift their heads and chest up from a belly-down position.
Choice A is not correct because it is normal for a 3-month-old infant to be unable to roll from back to abdomen.
Choice B is not correct because it is normal for a 3-month-old infant to be unable to use a pincer grasp to pick up objects.
Choice D is not correct because it is normal for a 3-month-old infant to be unable to sit without support.
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