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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Recommend the client begin behavioral therapy: Behavioral therapy, particularly cognitive-behavioral therapy (CBT), is the first-line treatment for gambling disorder. It helps the client identify triggers, develop coping strategies, and change maladaptive behaviors associated with gambling.
B. Request a referral for electroconvulsive therapy: Electroconvulsive therapy (ECT) is not indicated for gambling disorder. ECT is primarily used for severe depression or treatment-resistant psychiatric conditions and does not address behavioral addictions.
C. Request a prescription for a stimulant medication: Stimulants are not recommended for treating gambling disorder and could worsen impulsivity or addictive behaviors. Pharmacologic therapy, when used, typically involves SSRIs or opioid antagonists for specific symptom management.
D. Inform the client that hospitalization is not used for the treatment of a gambling disorder: While outpatient therapy is common, some clients may require short-term hospitalization if comorbid psychiatric conditions or severe psychosocial crises are present. Blanket statements about hospitalization are not appropriate as part of individualized care planning.
Correct Answer is D
Explanation
A. "Our children can stay up as late as they prefer.": This statement reflects permissive parenting, which is characterized by few rules, limited discipline, and high responsiveness to the child’s desires. Parents allow children considerable freedom, often prioritizing the child’s wishes over structure or boundaries.
B. "We make decisions as a family.": This statement reflects authoritative parenting, which emphasizes democratic decision-making, open communication, and balanced expectations. Children are involved in discussions, but parents still provide guidance and set reasonable limits.
C. "Our children are allowed to make their own choices.": Allowing children to make their own choices reflects permissive or laissez-faire parenting. While autonomy is encouraged, there is typically less emphasis on rules, boundaries, or consistent discipline, which differs from the control-focused approach of authoritarian parenting.
D. "We expect our children to do what we say without any questions.": This statement reflects authoritarian parenting, which is characterized by high demands, strict rules, and limited flexibility. Parents expect obedience without discussion, prioritize control over warmth, and often enforce discipline without explaining reasoning.
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