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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Passage of meconium stool is a normal and expected event in the first 24-48 hours of life. The absence of meconium stool can be indicative of bowel obstruction or other underlying medical conditions, and requires further investigation and evaluation by the healthcare team. The other options are important pieces of information, but they do not carry the same level of urgency as the absence of meconium stool.
Correct Answer is D
Explanation
When a Rh-negative mother gives birth to a Rh-positive baby, there is a risk that the mother's immune system will develop antibodies against the Rh-positive factor. These antibodies can cross the placenta in future pregnancies and atack the Rh-positive fetus, leading to hemolytic disease of the newborn. Rho(D) immune globulin is given after delivery to prevent the formation of these antibodies. The PN should explain this to the client and encourage her to reconsider her refusal of the treatment. Answers A, B, and C are incorrect and do not provide accurate information.
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