The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

Encourage voiding

Notify healthcare provider

Inspect the perineal pad

Monitor vital signs

Answer and Explanation

The Correct Answer is A

Encourage voiding: A boggy uterus that is displaced above and to the right of the umbilicus often indicates that the bladder may be distended, which can push the uterus out of its normal position and prevent it from contracting properly. Encouraging the client to void can help to reduce bladder distension and allow the uterus to return to its normal position and firm up.

Notify healthcare provider: While this may ultimately be necessary if the problem persists or other complications are noted, the immediate action should be to address the most common cause of uterine displacement, which is bladder distension.

Inspect the perineal pad:
Checking the perineal pad can give clues about the amount of lochia (postpartum vaginal discharge). However, in this scenario, the priority lies in addressing the potential uterine atony.

Monitor vital signs:
While it's important to monitor vital signs, especially in postpartum clients, the priority here is recognizing and managing the potential uterine atony.

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Correct Answer is A

Explanation

Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.

Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.

Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.

Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.

A. The diaphragm must be refitted after childbirth B. The most effective form of contraception is a diaphragm C. The diaphragm should be inserted 2 to 4 hours before intercourse. D. Vaseline lubricant can be used when inserting the diaphragm

Correct Answer is A

Explanation

The diaphragm must be refitted after childbirth:
This statement is correct. After childbirth, especially vaginal delivery, there can be changes in the size and tone of the vagina. Therefore, it's important to be refitted for a diaphragm after giving birth.

The most effective form of contraception is a diaphragm:
This statement is not accurate. While the diaphragm is a reversible and user-controlled method, its effectiveness can vary. It requires correct and consistent use to be effective.

The diaphragm should be inserted 2 to 4 hours before intercourse:
This statement is partially correct. The diaphragm should be inserted no more than 2 hours before intercourse and should be left in place for at least 6 hours after intercourse.

Vaseline lubricant can be used when inserting the diaphragm:
This statement is incorrect. Oil-based lubricants, including Vaseline, can damage latex diaphragms. Water-based lubricants are recommended for use with diaphragms

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The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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