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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The MSAFP test measures the levels of alpha-fetoprotein (AFP) in the mother’s body.
AFP is a protein produced by the baby during pregnancy.
Too much AFP in the mother’s body may indicate that the baby is at risk of a neural tube defect, like spina bifida.
Choice A is incorrect because this test does not screen for gestational diabetes.
Choice B is incorrect because this test does not screen for fetal maturity.
Choice D is incorrect because this test does not screen for ABO incompatibility.

A. Administer misoprostol vaginally. B. Administer acetaminophen orally. C. Prepare the client for placement of an intrauterine pressure catheter. D. Recheck the client's temperature in 2 hr.

Correct Answer is B

Explanation

Acetaminophen can be used to reduce fever during pregnancy.
Choice A is incorrect because misoprostol is not used to treat fever during labor.
Choice C is incorrect because the placement of an intrauterine pressure catheter is not used to treat fever during labor.
Choice D is incorrect because simply rechecking the client’s temperature in 2 hours does not address the issue of the client’s fever.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is at 17 weeks of gestation and is scheduled to have a maternal serum alpha-fetoprotein (MSAFP) determination. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is in early labor with intact membranes and a temperature of 38.9°C (102°F). After notifying the provider, which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse caring for a child who has been put into a leg cast must be on alert for signs of nerve and muscle damage. Which symptom might be an early warning signal that the child has developed compartment syndrome?

The nurse is working with a group of caregivers of school-aged children discussing fractures. The nurse explains that a twist around the bone frequently associated with child abuse is what type of fracture?

The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client.

A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep. Which suggestion for sleeping should the nurse prioritize for this client?

A nurse is reinforcing teaching with the mother of a 2-month-old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?

A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?

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?