A nurse is monitoring a client following a cesarean birth 6 hr ago who received an IV bolus oxytocin immediately after birth but continues to have a boggy fundus. Which of the following should the nurse identify as the priority intervention?
Assess for bladder distention
Apply supplemental oxygen via nonrebreather mask.
Administer intramuscular methylergonovine.
Analyze coagulation studies.
The Correct Answer is A
A. Assess for bladder distention: A full bladder can prevent the uterus from contracting effectively, leading to a boggy fundus and increased risk of postpartum hemorrhage. Assessing and addressing bladder distention is the priority because it directly impacts uterine tone and hemorrhage prevention.
B. Apply supplemental oxygen via nonrebreather mask: Oxygen may be necessary if the client shows signs of hypoxia or shock, but it does not address the primary cause of a boggy uterus. The priority is to correct the underlying issue affecting uterine contraction.
C. Administer intramuscular methylergonovine: Methylergonovine is used to promote uterine contraction, but pharmacologic intervention should follow initial assessment to identify reversible causes such as bladder distention. Administering medication without assessment could overlook a correctable mechanical issue.
D. Analyze coagulation studies: Coagulation studies are important if bleeding persists or coagulopathy is suspected, but they are not the immediate priority in a client with a boggy fundus shortly after birth. Immediate interventions to promote uterine contraction take precedence.
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Related Questions
Correct Answer is D
Explanation
A. Outer posterior aspect of upper arm: This site, the deltoid muscle, is appropriate for small-volume IM injections (up to 1 mL). However, it is limited by muscle size and is not preferred for larger volume or more irritating medications.
B. Upper thigh: The vastus lateralis muscle of the anterior thigh is a common IM site, particularly in infants and young children. While suitable, it may be less preferred in adults unless other sites are contraindicated.
C. Abdomen: The abdomen is not used for intramuscular injections; it is a common site for subcutaneous injections, such as insulin or heparin. Administering an IM injection in the abdomen would risk improper absorption and injury.
D. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections in adults because it is away from major nerves and blood vessels, allows for larger volumes of medication, and has a consistent muscle mass. It minimizes the risk of complications and is considered the safest IM injection site.
Correct Answer is D
Explanation
A. “I will overarticulate words when speaking.": Overarticulating words can distort speech and make it more difficult for a client with hearing loss to understand. Clear, normal articulation combined with visual cues is more effective for communication.
B. “I will repeat words not heard by the client": Repeating words is useful, but it is a secondary strategy. Effective communication begins with proper positioning and visual cues, which enhance understanding before repetition is needed.
C. “I will speak in a loud voice when addressing the client.": Speaking louder does not necessarily improve comprehension and can distort speech. Many clients with hearing loss benefit more from clear, normal-volume speech and lip-reading rather than increased volume.
D. “I will face the client when speaking": Facing the client allows them to use visual cues, such as lip reading and facial expressions, which significantly improves understanding. This technique is the primary and most effective communication strategy for clients with hearing loss.
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