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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Anticoagulants for 6 weeks. This is because the client’s symptoms suggest that she has deep vein thrombosis (DVT), which is a blood clot in a deep vein of the leg. DVT is a serious condition that can lead to pulmonary embolism, which is a blockage of a blood vessel in the lungs. The treatment for DVT involves anticoagulants, which are drugs that prevent blood clots from growing or forming new ones. The duration of anticoagulant therapy depends on the risk factors and severity of DVT, but it is usually at least 6 weeks.
Choice A is wrong because gentle massage of the affected leg can dislodge the clot and cause a pulmonary embolism.
Choice C is wrong because passive leg exercises can increase blood flow and worsen pain and swelling.
Choice D is wrong because the application of ice to the affected leg can reduce inflammation but does not treat the underlying clot.
Correct Answer is A
Explanation
The Moro reflex was elicited. This is because the Moro reflex is a normal newborn reflex that occurs when the baby is startled by a loud noise or a sudden movement. The baby responds by extending the arms and legs, opening the hands, and then bringing the arms and legs back to the chest.
The Moro reflex is present at birth and disappears by 3 to 6 months of age.
Choice B is wrong because this is not abnormal for a full-term infant. The Moro reflex is a sign of a healthy nervous system and brain development.
Choice C is wrong because there is no evidence of an abnormality in the musculoskeletal system. The Moro reflex does not indicate any problems with the bones or muscles of the baby.
Choice D is wrong because the full-term infant should react to sudden movement. The Moro reflex is a protective response that helps the baby cling to the mother in case of danger.
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