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 D
Explanation
An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.
Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.
Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.
Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.
Correct Answer is A
Explanation
During pregnancy, it is important for the client to consume a balanced and nutritious diet that includes adequate protein, vitamins, and minerals. However, clients with nausea and vomiting may have difficulty tolerating certain foods, particularly those that are high in fat or spicy. Cheeseburgers and French fries are typically high in fat and can exacerbate nausea, making them a poor choice for a client with this symptom.
Baked chicken with rice and pasta with steamed vegetables are both healthier options that can provide the client with adequate nutrition.
Baked potato chips and lemonade may be a suitable snack for some clients, but the high salt content of the chips may exacerbate fluid retention, which can be a concern for clients with pyelonephritis. The PN should encourage the client to choose healthier options and avoid foods that are likely to exacerbate her symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today