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

Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.

Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.

Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.

Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.

A. After ceasing breastfeeding the diaphragm should be resized. B. Use an alternate form of contraception until a new diaphragm is obtained. C. If no more than 20 pounds was gained during pregnancy, the diaphragm is safe to use. D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated

Correct Answer is B

Explanation

A. After ceasing breastfeeding, the diaphragm should be resized: Breastfeeding can affect vaginal lubrication and elasticity. It might be advisable to have the diaphragm refitted after childbirth and after breastfeeding stops. However, this choice doesn't directly address the current situation.

B. Use an alternate form of contraception until a new diaphragm is obtained: This is a reasonable suggestion. Using a diaphragm that was fitted before pregnancy might not offer adequate protection due to potential changes in the cervix's size or shape after childbirth.

C. If no more than 20 pounds were gained during pregnancy, the diaphragm is safe to use: Weight gain during pregnancy can affect the size and shape of the vagina and cervix. However, specifying a particular weight gain as a safety criterion for using the diaphragm isn't entirely accurate.

D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated: This is a cautious approach. Waiting until the diaphragm size is confirmed by a healthcare professional could be prudent to ensure the correct fit and effectiveness.

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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 B

Explanation

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