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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The information that poses the greatest risk for developing postpartum endometritis in this situation is that the client experienced spontaneous rupture of membranes (SROM) for 36 hours prior to delivery. SROM for an extended period of time increases the risk of infection, including postpartum endometritis, which is an infection of the uterus. The practical nurse (PN) should recognize this risk factor and monitor the client closely for signs of infection. The other information listed may also be important to consider, but SROM for 36 hours poses the greatest risk for developing postpartum endometritis in this situation.

A. Is openly hostile to others for no apparent reason. B. Talks to voices only he can hear. C. Repeatedly tries to commit suicide. D. Tries to run the unit, telling everyone what to do and when to do it.

Correct Answer is A

Explanation

A male client with paranoia can be expected to exhibit behavior such as being **openly hostile to others for no apparent reason**. Paranoia is a mental health condition characterized by intense and irrational mistrust or suspicion of others. This can lead to hostility and aggression towards others, even when there is no apparent reason for it.

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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?

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Correct Answer is B

Explanation

The practical nurse is evaluating a male client with paranoia. Which behavior can this client be expected to exhibit?

Correct Answer is A

Explanation

Following the prenatal clinic's screening protocol, the practical nurse (PN) is preparing laboratory prescriptions for clients who are scheduled to be seen today. Which screening test should be scheduled for a client who is gravida 4 para 3 at 16-weeks gestation?

The practical nurse (PN) enters an examination room to gather routine health information for a teenage female client who is accompanied by her mother. Which action by the PN is likely to facilitate accurate responses to personal and social history questions?

The practical nurse (PN) is contributing to the plan of care for a toddler with failure to thrive due to inadequate caloric intake. Which observation should the PN monitor to best help develop interventions?

The practical nurse (PN) caring for a 3-month-old boy one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the PN take?

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?

The practical nurse (PN) notes several nutritional goals in a standardized plan of care used in the antepartum clinic. Which client goal takes priority?

When preparing to assist in a scoliosis screening clinic, the practical nurse (PN) should identify which age group will be included in the examinations?

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the practical nurse (PN) to monitor?