A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?
Assist the client to void then reassess the fundus.
Document the findings as within normal limits.
Gently massage the client's fundus.
Encourage the client to ambulate.
The Correct Answer is A
Choice A rationale:
Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.
Choice B rationale:
Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.
Choice C rationale:
Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.
Choice D rationale:
Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Vitamin E is essential for cell function and acts as an antioxidant. While vitamin E is important during pregnancy, there is no specific recommendation to increase its intake during gestation. The recommended daily allowance (RDA) for vitamin E during pregnancy is 15 mg.
Choice B rationale:
Vitamin D is crucial for calcium absorption and bone health. However, it is not explicitly advised to increase vitamin D intake during pregnancy, and it largely depends on the individual's baseline vitamin D levels. The RDA for vitamin D during pregnancy is 600 IU.
Choice C rationale:
Fiber is essential during pregnancy as it helps prevent constipation, which is a common problem due to the increased levels of progesterone. A high-fiber diet also helps in maintaining healthy blood sugar levels, which is important to avoid gestational diabetes.
Choice D rationale:
Calcium is vital for the development of the baby's bones and teeth. While it is an important nutrient during pregnancy, the body's ability to absorb calcium improves during pregnancy, so the recommended intake does not increase as much as fiber.
Correct Answer is B
Explanation
Choice A rationale:
High calcium levels are not typically associated with the use of anastrozole, an aromatase inhibitor. Aromatase inhibitors work by blocking the conversion of androgens to estrogens, and they do not directly impact calcium levels.
Choice B rationale:
Muscle and joint pain is a common side effect of aromatase inhibitors like anastrozole. These medications can lead to musculoskeletal discomfort, including joint stiffness and pain, which the nurse should inform the client about to ensure she is aware of potential adverse effects.
Choice C rationale:
Heart failure is not a known side effect of anastrozole. The drug's primary concern is its impact on the musculoskeletal system, particularly causing joint and muscle pain.
Choice D rationale:
Polyphagia, which refers to excessive hunger and increased food intake, is not associated with the use of anastrozole. This choice is unrelated to the side effects of the medication and can be ruled out.
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