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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Restricting protein intake to less than 40 g/day is not appropriate for a client with preeclampsia with severe features. While protein restriction might be advised in some cases of preeclampsia, it is not a priority in severe cases where the focus is on managing potential complications.

Choice B rationale:

Initiating seizure precautions is essential in managing a client with preeclampsia with severe features. Preeclampsia can lead to eclampsia, a condition characterized by seizures. Seizure precautions involve implementing measures to prevent injury during a seizure, such as padding the side rails of the bed, ensuring a clear environment, and having emergency equipment readily available.

Choice C rationale:

Initiating an infusion of 0.9% sodium chloride at 150 ml/hr is not directly related to managing preeclampsia with severe features. Although intravenous fluids may be necessary in some cases, the priority in this situation is to prevent and manage potential seizures.

Choice D rationale:

Encouraging the client to ambulate twice per day is not appropriate for a client with preeclampsia with severe features. Bed rest is often recommended in severe cases to reduce stress on the cardiovascular system and decrease the risk of complications.

A. Empty the bladder. B. Nothing by mouth for 4 hours. C. Ingest 3-liters of water. D. Nipple stimulation.

Correct Answer is A

Explanation

Choice A rationale:

Before an amniocentesis, it is essential for the client to empty their bladder. A full bladder can interfere with the procedure, as it may obstruct the needle's entry into the uterus and increase the risk of accidental bladder puncture.

Choice B rationale:

Nothing by mouth (NPO) for 4 hours is not necessary for an amniocentesis. It is a relatively simple and quick procedure that does not require fasting.

Choice C rationale:

Ingesting 3 liters of water is not indicated before an amniocentesis. While some ultrasound examinations may require a full bladder, this is not the case for an amniocentesis.

Choice D rationale:

Nipple stimulation is not relevant or necessary before an amniocentesis. Nipple stimulation can trigger uterine contractions, which might be undesirable before the procedure, especially if the client is not in labor.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Prior to an amniocentesis, what action by the client will need to be completed?

Correct Answer is A

Explanation

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