The practical nurse (PN) determines that a client who is one day postpartum has a moderate amount of lochia rubra and the uterus is firm, dextroverted, and three fingerbreadths above the umbilicus. Which should be the PN's initial action?
Provide a stool softener for constipation.
Assess the bladder for distension.
Check the hemoglobin to determine uterine hemorrhage.
Massage the uterus to decrease atony.
The Correct Answer is B
Correct Answer: B.
A. Providing a stool softener for constipation might be necessary postpartum but isn't the initial action indicated by the client's current status.
B. Assessing the bladder for distension is crucial because a distended bladder can displace the uterus and impede its ability to contract properly, leading to uterine atony and increased bleeding.
C. Checking the hemoglobin to determine uterine hemorrhage is important but might not be the initial step needed based on the client's condition.
D. Massaging the uterus to decrease atony is a potential intervention, but assessing for bladder distension takes priority in this scenario to prevent uterine displacement.
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Related Questions
Correct Answer is D
Explanation
A. Ineffective pain management reported while using morphine PCA is concerning but may not be immediately life-threatening.
B. Inability to void after discontinuing an indwelling catheter should be addressed but might not require immediate attention.
C. Oral ice chips eaten after vomiting postoperatively might need monitoring, but it's not typically an urgent issue.
D. Coffee-ground secretions draining via nasogastric tube suction could indicate bleeding in the upper gastrointestinal tract, which requires immediate attention due to the potential for severe
bleeding.
Correct Answer is B
Explanation
A. Requesting that the man leave violates the patient's right to privacy and intimacy.
B. In this situation, the practical nurse (PN) shouldexit the room and quietly close the door. This approach respects the privacy and dignity of the older female client and her male friend while maintaining professionalism and discretion. It avoids embarrassing or shaming the couple and allows them their personal space.
C. Asking when the nurse should return doesn't handle the immediate situation effectively.
D. Reporting the incident to the family might be an option, but the immediate action is to maintain appropriate boundaries by asking the man to leave.
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