The nurse is caring for a client who delivered 6 hours ago.
The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

Monitor the client’s vital signs.

Notify the healthcare provider.

Inspect the perineal pad.

Encourage the client to void.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice B rationale

Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.

Choice C rationale

Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice D rationale

Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.

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Correct Answer is ["300"]

Explanation

Step 1:

4 grams ÷ 20 grams × 500 mL = 100 mL

Step 2:

100 mL ÷ 20 minutes × 60 minutes/hour = 300 mL/hour

Answer:

300 mL/hour

A. Administer oxygen via facemask. B. Change the client’s position. C. Turn off the oxytocin infusion. D. Assess cervical dilatation.

Correct Answer is B

Explanation

Choice A rationale

Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.

Choice B rationale

Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.

Choice C rationale

Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.

Choice D rationale

Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.

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The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?

Correct Answer is ["300"]

Explanation

The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

Correct Answer is B

Explanation

A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations.What should the nurse do next?

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant’s eyes. He asks the nurse what is the purpose of the ointment.The nurse would be correct in stating that the purpose for using the ointment is to:

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

The nurse is caring for a client who delivered 6 hours ago.
The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?