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

Endometritis. This is because the client's symptoms suggest that she has endometritis, which is an infection of the lining of the uterus. Endometritis is a common postpartum complication that can occur after vaginal or cesarean delivery. The client may also have foul-smelling vaginal discharge, chills, and fatigue.

Choice B is wrong because cystitis is an infection of the bladder that causes pain or burning during urination, not cramping.

Choice C is wrong because dehydration does not cause fever or persistent cramping.

Choice D is wrong because hypovolemic shock is a condition of low blood volume that causes low blood pressure, rapid pulse, and pale skin, not fever or cramping.

A. Clear the respiratory tract. B. Dry the infant off and cover the head. C. Stimulate the infant to cry. D. Clamp the umbilical cord.

Correct Answer is A

Explanation

Clear the respiratory tract. This is because clearing the respiratory tract is the first step in the initial care of a newborn following vaginal delivery. The respiratory tract includes the nose, mouth, and lungs.

Clearing the respiratory tract helps the baby breathe more easily and prevents aspiration of amniotic fluid, blood, or mucus. The nurse can use a bulb syringe or a suction device to gently remove any fluid from the baby's nose and mouth.

Choice B is not correct because drying the infant off and covering the head is not the first action to take. Drying and covering the infant helps prevent heat loss and hypothermia, which are important for newborn care. However, this should be done after clearing the respiratory tract.

Choice C is not correct because stimulating the infant to cry is not the first action to take. Stimulating the infant to cry can help expand the lungs and improve oxygenation, which is also important for newborn care. However, this should be done after clearing the respiratory tract.

Choice D is not correct because clamping the umbilical cord is not the first action to take. Clamping and cutting the umbilical cord separates the baby from the placenta, which is no longer needed after birth. However, this should be done after clearing the respiratory tract.

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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

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

Correct Answer is A

Explanation

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Correct Answer is A

Explanation

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

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

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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?

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.

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A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

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