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 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.

A. Cold stress B. Thermogenesis C. Shivering D. Brown fat production

Correct Answer is A

Explanation

This action helps to prevent cold stress. This is because cold stress is a condition where the newborn's core temperature drops below 36.5°C and they use energy and oxygen to generate warmth. This can lead to hypoglycemia, metabolic acidosis, hypoxia, and an increased risk of infection.

Placing the newborn under a radiant warmer provides thermal stability and prevents heat loss by radiation.

Choice B is wrong because thermogenesis is the process of heat production, not a complication.

Choice C is wrong because shivering is a mechanism of heat production in adults, not in newborns.

Choice D is wrong because brown fat production is a normal feature of newborns that helps them generate heat by lipolysis.

Here is an image of a newborn under a radiant warmer.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent?

Correct Answer is A

Explanation

During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve:

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?