The practical nurse (PN) 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 PN take?
Encourage voiding.
Monitor vital signs.
Notify healthcare provider.
Inspect the perineal pad.
The Correct Answer is A
If the practical nurse (PN) is caring for a client who delivered 6 hours ago and assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus, the PN should encourage the client to void. A full bladder can displace the uterus and prevent it from contracting properly, leading to a boggy uterus. Encouraging the client to void can help empty the bladder and allow the uterus to contract and return to its normal position. The other actions listed may also be appropriate in some situations, but encouraging voiding is the most appropriate action in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A positive indirect Coombs' test indicates that the mother has developed Rh antibodies against the baby's Rh-positive blood. This finding can result in hemolytic disease of the newborn, which is a condition in which the mother's Rh antibodies atack the baby's red blood cells, causing destruction and potential anemia.
The baby may require phototherapy for physiologic jaundice, but the Coombs' test result indicates a different issue.
The presence of an infectious blood-borne disease cannot be determined from this test.
The mother may still need Rho (D) immune globulin injections after delivery of an Rh-positive baby.
Correct Answer is C
Explanation
The practical nurse should report to the charge nurse that the client is near delivery, as the client's signs indicate that she is in the transition phase of labor and is likely to deliver soon. The PN should also assess the client's vital signs, fetal heart rate, and pain level, and prepare the delivery equipment.
The husband can be asked to provide emotional support to the client during labor.
The rapid response team may be called in case of a medical emergency, but this is not indicated based on the information given.
Checking the time, the last PRN narcotic analgesic was given is also not indicated at this point, as the client is close to delivery and may not have time for medication to take effect.
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