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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing again, and resuming the feeding.
The other options are not correct because:
B. Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.
C. Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
D. Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.
Correct Answer is C
Explanation
A. Checking for kinks in the drainage tubing is important, but the observed clots and thick red fluid suggest potential complications that require immediate attention and should be reported. B. Waiting for an hour to observe again could delay necessary interventions if there's an issue with bleeding or clot formation, so reporting immediately is more prudent.
C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D. Stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation. Reporting to a superior nurse allows for prompt evaluation and intervention.
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