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.
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Related Questions
Correct Answer is D
Explanation
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
Correct Answer is B
Explanation
The priority action for the practical nurse (PN) to take while caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg is to remove clothing and cover the burned area with a cool damp cloth. This will help to cool the burn and reduce pain.
Anticipating rehydration of 1000 mL/6 hr. with normal saline (Option A) is an important intervention for burn patients, but it is not the first priority. Completely flushing the burned area with water or sterile saline (Option C) may be appropriate in some cases, but it is not the first intervention that should be implemented. Collecting data such as vital signs, blood gases, height and weight (Option D) is also important, but it is not the first priority.
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