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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Compartment syndrome is a condition where increased pressure within a muscle compartment causes muscle and nerve damage along with pain.
One of the symptoms of compartment syndrome is severe pain that increases with the stretching of muscles.
Choice A is not correct because blue-looking nail beds on the toes are not a symptom of compartment syndrome.
Choice B is not correct because a weak femoral pulse is not a symptom of compartment syndrome.
Choice C is not correct because the inability to plantarflex the foot is not a symptom of compartment syndrome.
Correct Answer is C
Explanation
The nurse should recommend an increased fiber and fluid intake in the diet to help relieve constipation during pregnancy.
Eating more foods with fiber such as fruits, vegetables, whole grains, beans, nuts, and seeds can help fight constipation123.
Regular use of glycerine suppositories or laxatives is not recommended during pregnancy without consulting a healthcare provider first4.
Maintenance of good posture is not directly related to relieving constipation.
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