A patient is admitted to the postpartum unit one hour after a sterile vaginal delivery of a normal neonate weighing 8 pounds 2 ounces (3.7 kg). When the client's fundus becomes boggy and displaced above the umbilicus, which action should the practical nurse (PN) take first?
Take the vital signs and open the IV infusion rate of oxytocin.
Notify the registered nurse (RN) that the client's bladder is distended.
Put the infant to breast to suckle and stimulate oxytocin secretion.
Massage the fundus and expel retained lochia and clots.
The Correct Answer is D
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
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Related Questions
Correct Answer is C
Explanation
Limited abduction of the legs in a newborn can be a sign of developmental dysplasia of the hip (DDH), a condition in which the hip joint is not properly formed. The practical nurse (PN) should notify the healthcare provider of this finding so that further assessment and appropriate intervention can be initiated.
Performing range of motion to the joint (A) is not appropriate without a healthcare provider's order. Continuing care as if this is a normal finding (B) is not appropriate because limited abduction of the legs in a newborn can be a sign of DDH. While documenting the finding in the record (D) is important, notifying the healthcare provider is the most important action for the PN to take next.
Correct Answer is D
Explanation
To help increase an older adult's magnesium level following a hysterectomy, the practical nurse (PN) should suggest that the client increase her intake of protein in fish. Fish is a good source of magnesium, which is an essential mineral that plays a role in many bodily functions. Increasing the intake of magnesium-rich foods such as fish can help raise the client's magnesium level and improve her overall health. The other foods listed may also provide some nutritional benefits, but fish is the best choice for increasing magnesium intake in this situation.
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