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 D
Explanation
Choice A reason: Advising the client to place one nitroglycerin tablet under his tongue as a precaution is a dangerous action for the nurse, as this can cause severe hypotension and cardiovascular collapse due to the interaction between tadalafil and nitroglycerin. This is a contraindicated choice.
Choice B reason: Telling the client to have someone bring him to an emergency department immediately is an unnecessary action for the nurse, as there is no evidence of any serious adverse reaction or complication from tadalafil. This is an overreaction choice.
Choice C reason: Instructing the client to increase his intake of oral fluids until the skin flushing is relieved is not an appropriate action for the nurse, as this does not address the cause of the flushing, which is vasodilation due to tadalafil. This is a distractor choice.
Choice D reason: Reassuring the client that skin flushing is a common side effect of the medication is an appropriate action for the nurse, as this can calm the client and educate him about the expected effects of tadalafil. Therefore, this is the correct choice.
Correct Answer is B
Explanation
Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.
Choice B reason: This is the correct answer because maintaining a continuous infusion of IV fluids per prescription is essential to prevent dehydration and electrolyte imbalance in the infant. The infant may have significant fluid loss due to vomiting and poor intake.
Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.
Choice D reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.
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