When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm and three fingerbreadths above the umbilicus. What action should the nurse implement first?
Check for a distended bladder.
Review the hemoglobin to determine hemorrhage.
Massage the uterus to decrease atony.
Increase intravenous infusion.
The Correct Answer is A
Choice A reason: This is the correct answer because a distended bladder can cause uterine displacement and interfere with uterine contraction, leading to increased bleeding and risk of infection. The nurse should check for bladder fullness and encourage the client to void or catheterize if necessary.
Choice B reason: Reviewing the hemoglobin to determine hemorrhage is an important action, but not the first one. The nurse should first identify and correct the cause of bleeding, such as bladder distension or uterine atony, before checking for blood loss and anemia.
Choice C reason: Massaging the uterus to decrease atony is not indicated in this case, because the uterus is already firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D reason: Increasing intravenous infusion is not the first action, because it may worsen bleeding by increasing blood pressure and diluting clotting factors. The nurse should first assess and manage bleeding before administering fluids or blood products as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because getting an eye examination with an ophthalmologist annually is an important point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the eyes, leading to vision problems and eye diseases such as diabetic retinopathy, cataracts, and glaucoma. Regular eye check-ups can help detect and treat these conditions early and prevent blindness.
Choice B reason: Arranging diet schedule around three regular meals a day is not a sufficient point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus is a condition that affects the body's ability to produce or use insulin, a hormone that regulates blood glucose levels. Eating three regular meals a day may not be enough to control blood glucose levels and prevent complications such as hypoglycemia or hyperglycemia. The nurse should teach the client to follow a balanced diet that includes carbohydrates, proteins, fats, vitamins, minerals, and fiber, and to eat smaller portions more frequently throughout the day.
Choice C reason: Using garlic, herbs, and spices will improve the flavor of food is not a specific point for disease and symptom management for a client with type 2 diabetes mellitus. Garlic, herbs, and spices are natural ingredients that can enhance the taste and aroma of food, but they do not have a direct impact on blood glucose levels or diabetes complications. The nurse should teach the client to limit the intake of salt, sugar, and saturated fats, and to choose foods that are low in glycemic index and high in antioxidants.
Choice D reason: Inspecting feet every month for ingrown nails, cuts, and calluses is not a frequent enough point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the feet, leading to reduced sensation, poor circulation, infection, ulceration, and amputation. The nurse should teach the client to inspect feet every day for any signs of injury or infection, and to wash, dry, moisturize, and protect them properly. The nurse should also advise the client to wear comfortable shoes and socks, avoid walking barefoot, and seek medical attention for any foot problems.
Correct Answer is C
Explanation
Choice A reason: Conversion of the client's PPD test from negative to positive is not the most important information for the nurse to note, as this is an expected finding for a client who has been exposed to tuberculosis and does not affect the administration of isoniazid. This is a distractor choice.
Choice B reason: History of intravenous drug abuse is not the most important information for the nurse to note, as this is not directly related to the use of isoniazid and does not contraindicate its administration. This is another distractor choice.
Choice C reason: Current diagnosis of hepatitis B is the most important information for the nurse to note, as this can increase the risk of hepatotoxicity and liver damage from isoniazid, which requires close monitoring and possible dose adjustment. Therefore, this is the correct choice.
Choice D reason: Length of time of the exposure to tuberculosis is not the most important information for the nurse to note, as this does not influence the dosage or frequency of isoniazid and does not indicate any complication or adverse reaction. This is another distractor choice.
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