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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Take the medication with an antacid if gastrointestinal upset occurs.": Antacids can bind to tetracycline and significantly reduce its absorption, making the antibiotic less effective. Clients should be instructed to avoid taking tetracycline simultaneously with antacids.
B. "Use a hormonal contraceptive when sexually active.": Tetracycline can decrease the effectiveness of hormonal contraceptives, so clients should use an additional form of contraception rather than relying solely on hormonal methods. This statement should emphasize using a backup method rather than suggesting hormonal contraceptives alone.
C. "Avoid taking this medication with milk.": Calcium-containing products, including milk, can bind to tetracycline and impair absorption. Clients should take the medication with water and separate it from dairy products by at least 2 hours to ensure effectiveness.
D. "Exposure to direct sunlight can help this medication improve acne.": Tetracycline increases photosensitivity, making clients more prone to sunburn. Clients should avoid direct sunlight and use protective measures such as sunscreen, hats, and protective clothing, rather than seeking sun exposure.
Correct Answer is B
Explanation
A. Furosemide: Furosemide is a loop diuretic that promotes potassium excretion. It does not need to be withheld for a mildly elevated potassium level; in fact, it may help lower potassium levels in hyperkalemia.
B. Spironolactone: Spironolactone is a potassium-sparing diuretic that can increase serum potassium. With a level of 5.2 mEq/L, administering spironolactone could worsen hyperkalemia and increase the risk of cardiac complications, so the dose should be withheld and the provider notified.
C. Metoprolol: Metoprolol, a beta-blocker, does not typically raise potassium levels significantly. While beta-blockers can slightly affect potassium, withholding is not indicated solely based on a potassium level of 5.2 mEq/L.
D. Atorvastatin: Atorvastatin, a lipid-lowering agent, has no effect on serum potassium levels and does not need to be withheld in this situation. It can be continued safely.
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