The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

Blood pressure

Amount of lochia

Fulness of the bladder

Level of pain

Answer and Explanation

The Correct Answer is C

Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.

Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.

Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.

Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.

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Correct Answer is A

Explanation

The baby sleeps with the mother in bed. This is because sleeping with the baby in the same bed increases the risk of sudden infant death syndrome (SIDS), suffocation, strangulation, and entrapment. The nurse should have assessed the mother’s sleeping arrangements for the baby and provided education on safe sleep practices before discharge. The nurse should advise the mother to place the baby on a firm surface, such as a crib or bassinet, in the same room but not in the same bed as the mother.

Choice B is wrong because having windows covered with screens is not a sign of inadequate home assessment. Screens can help prevent insects and other animals from entering the home and posing a health hazard.

Choice C is wrong because having a refrigerator in the kitchen is not a sign of inadequate home assessment. A refrigerator can help store food and breast milk safely and prevent spoilage and contamination.

Choice D is wrong because having a changing area for the baby is not a sign of inadequate home assessment. A changing area can help keep the baby clean and comfortable and prevent diaper rash and infection.

A. Administer oxytocin. B. Observe for pooling of blood under the buttocks. C. Check the client's blood pressure. D. Massage the client's fundus.

Correct Answer is D

Explanation

Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.

Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

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The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

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Naxlex Comprehensive Predictor Exams

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

Correct Answer is A

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is: