A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

Fundal height below the umbilicus

Decreased urge to void

Increased urine output

Displaced fundus from the midline

Answer and Explanation

The Correct Answer is D

A) Fundal height below the umbilicus:

In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.

B) Decreased urge to void:

A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.

C) Increased urine output:

Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.

D) Displaced fundus from the midline:

A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.

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Correct Answer is C

Explanation

C) Massage the client's fundus to promote contractions:

Given the client's symptoms of excessive bleeding (soaked perineal pad in 10 minutes) and signs of hypovolemia (pale skin color, feeling weak, and light-headedness), massaging the client's fundus to promote contractions is the priority action. This intervention helps stimulate uterine contractions, which can aid in controlling postpartum hemorrhage by reducing uterine atony, a common cause of excessive bleeding after childbirth.

A) Administer oxytocin by continuous IV infusion:

While administering oxytocin by continuous IV infusion is a crucial intervention to promote uterine contractions and control bleeding in postpartum hemorrhage, massaging the fundus is the initial action to stimulate contractions directly. Oxytocin administration can follow fundal massage if the bleeding persists or worsens.

B) Tilt the client onto her right side with her legs elevated to at least 30°:

Positioning the client on her right side with legs elevated can improve venous return and cardiac output, but it is not the priority action in this scenario. Immediate treatment to address the potential cause of postpartum hemorrhage takes precedence over positioning adjustments.

D) Insert an indwelling urinary catheter:

Inserting a urinary catheter may be necessary to monitor urinary output and assess for bladder distention, especially if the client's fluid status needs close monitoring. However, it is not the priority action in this scenario, where addressing postpartum hemorrhage is the immediate concern

A. Dry the infant off and cover the head. B. Stimulate the infant to cry. C. Cut the umbilical cord. D. Clear the respiratory tract.

Correct Answer is D

Explanation

A) Dry the infant off and cover the head:

While drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation, clearing the respiratory tract takes precedence immediately after delivery to ensure adequate breathing and oxygenation.

B) Stimulate the infant to cry:

While it is essential for newborns to establish effective respiratory efforts, stimulating the infant to cry is not the first action indicated after delivery. Crying may naturally occur as a response to the new environment, but it is not a reliable indicator of effective respiratory function.

C) Cut the umbilical cord:

Cutting the umbilical cord is typically done after the initial steps of newborn care, including clearing the respiratory tract. It is important to ensure that the infant is breathing adequately before attending to other tasks such as cord cutting.

D) Clear the respiratory tract:

Clearing the newborn's respiratory tract is the priority action immediately after delivery to ensure that the airway is clear of any amniotic fluid or debris, facilitating effective breathing and oxygenation. This may involve suctioning the mouth and nose as needed to remove any secretions and ensure unobstructed airflow.

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A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is D

Explanation

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