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?

Encourage the client to nurse more frequently so her milk will come in.

Increase IV ﬂuids.

Ask the client to empty her bladder.

Report the client's temperature elevation.

Answer and Explanation

The Correct Answer is C

Choice A reason: Encourage the client to nurse more frequently so her milk will come in is incorrect, as this action is not related to the data collected by the nurse. The nurse notes that the client's breasts are soft, which indicates that the milk has not come in yet. This is normal and expected for a client who is 14 hr postpartum, as milk production usually begins around 72 to 96 hr after birth. The nurse should encourage the client to nurse frequently and eﬀectively to stimulate milk production and prevent engorgement.

Choice B reason: Increase IV ﬂuids is incorrect, as this action is not indicated by the data collected by the nurse. The nurse notes that the client's vital signs are within normal limits, except for a slight temperature elevation. Increasing IV ﬂuids can cause ﬂuid overload and electrolyte imbalance in the client. The nurse should maintain the IV ﬂuids at the prescribed rate and monitor the client's intake and output.

Choice C reason: Ask the client to empty her bladder is correct, as this action is indicated by the data collected by the nurse. The nurse notes that the client's fundus is firm but slightly deviated to the right, which suggests bladder distension. A full bladder can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.

Choice D reason: Report the client's temperature elevation is incorrect, as this action is not necessary for a slight temperature elevation in a postpartum client. The nurse notes that the client's temperature is 37.7° C (100° F), which is slightly above normal but within the range of expected findings for a postpartum client. A mild temperature elevation in the first 24 hr after birth can be due to dehydration, exertion, or hormonal changes and does not indicate infection. The nurse should encourage oral ﬂuid intake and monitor the temperature every 4 hr.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason: While ice packs can help reduce swelling and discomfort, they are not essential for preventing infection.

Choice B reason: Sit on an inﬂatable donut to protect the perineum is incorrect, as this can increase pressure and blood ﬂow to the perineum and delay healing. The nurse should advise the client to avoid sitting on hard or uneven surfaces and to use a pillow or a cushion for comfort.

Choice C reason: Perform hand hygiene before and after voiding is correct, as this can prevent contamination and infection of the perineal area. The nurse should instruct the client to wash their hands with soap and water or use an alcohol-based hand sanitizer before and after using the toilet.

Choice D reason: Blot the perineal area dry after voiding is correct, as this can keep the perineal area clean and dry and prevent irritation and infection. The nurse should instruct the client to use a clean, soft cloth or tissue and gently pat or blot the perineal area from front to back after voiding.

Choice E reason: Clean the perineal area from front to back is correct, as this can prevent bacteria from entering the vagina or urethra and causing infection. The nurse should instruct the client to use a peri-botle filled with warm water and squirt it over the perineal area from front to back after each voiding or bowel movement. The client should also change their perineal pad frequently and dispose of it properly.

A. Fetal head compression B. Polyhydramnios C. Maternal fever D. Umbilical cord compression

Correct Answer is D

Explanation

Choice A reason:
Fetal head compression is incorrect, as this factor can cause early decelerations in the fetal heart rate. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. Fetal head compression occurs as the fetus descends into the birth canal and does not pose a threat to the fetal well-being.

Choice B reason:
Polyhydramnios is incorrect, as this factor can cause variable or late decelerations in the fetal heart rate, depending on the underlying cause. Polyhydramnios refers to an excessive amount of amniotic ﬂuid, which can result from fetal anomalies, maternal diabetes, multiple gestation, or other conditions. Polyhydramnios can cause umbilical cord prolapse, uterine overdistension, or placental abruption, leading to reduced blood ﬂow and oxygen delivery to the fetus.

Choice C reason:
Maternal fever is incorrect, as this factor can cause late decelerations in the fetal heart rate. Late decelerations are symmetrical decreases in the FHR that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency. Maternal fever can increase maternal and fetal metabolism and oxygen demand, leading to fetal hypoxia and acidosis.

Choice D reason:
Umbilical cord compression is correct, as this factor can cause variable decelerations in the fetal heart rate. Variable decelerations are abrupt decreases in the FHR that vary in onset, duration, and depth, which indicate umbilical cord compression and reduced blood ﬂow to the fetus. Umbilical cord compression can occur due to cord prolapse, nuchal cord, short cord, or other causes. The nurse should reposition the client, administer oxygen, and prepare for delivery if indicated.

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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 about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

Correct Answer is D

Explanation

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