A firm fundus is palpated one finger breadth above the umbilicus and deviated to the left.
A small amount of lochia rubra is noted on the perineal pad.
Firmly massage the fundus.
Ask the client to empty their bladder and reassess.
Elevate the head of bed.
Notify the healthcare provider.
The Correct Answer is B
Choice A rationale
Massaging a fundus that is already firm is not necessary and could be uncomfortable for the client. The primary issue in this scenario is the deviated position of the fundus, which is a strong indicator of a full bladder. The bladder, when full, displaces the uterus upward and to the side, preventing it from contracting correctly. Massage is reserved for a boggy uterus.
Choice B rationale
A deviated fundus, especially one located above the umbilicus, is a classic sign of bladder distention. A full bladder prevents the uterus from contracting and descending into the pelvis, which can lead to uterine atony and hemorrhage. Emptying the bladder allows the uterus to return to its midline position and contract effectively, a crucial step in preventing postpartum bleeding.
Choice C rationale
Elevating the head of the bed does not address the underlying cause of the deviated fundus. The physiological problem is a full bladder, which mechanically displaces the uterus. While raising the head of the bed may improve the client's comfort or breathing, it will not resolve the uterine displacement or the risk of postpartum hemorrhage associated with it.
Choice D rationale
While notifying the healthcare provider may be necessary if other interventions are ineffective, it is not the immediate first action. The nurse should first attempt the least invasive intervention to correct the problem. A deviated fundus is a common postpartum finding caused by a full bladder, and the first line of action is to have the client void, as this is a simple and effective solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increasing weight loss is an incorrect characteristic. Nephrotic syndrome is marked by massive proteinuria, which leads to a decrease in plasma oncotic pressure. This fluid shift from the intravascular space to the interstitial space results in significant fluid retention, causing weight gain and edema, not weight loss. The body holds onto fluid, masking any potential muscle or fat wasting.
Choice B rationale
Increased urinary output is not a characteristic of nephrotic syndrome. The condition is associated with severe fluid retention and decreased plasma volume, leading to oliguria, or a decreased urinary output. The kidneys are not effectively filtering protein and fluid is being retained in the body, which directly reduces the amount of fluid that can be excreted as urine.
Choice C rationale
Generalized edema is the most common and striking characteristic of nephrotic syndrome. The massive loss of protein, particularly albumin, in the urine leads to a significant decrease in serum albumin levels. Albumin is crucial for maintaining plasma oncotic pressure. The resulting decrease in oncotic pressure causes fluid to shift from the bloodstream into the interstitial spaces, resulting in widespread or anasarca edema.
Choice D rationale
While hypertension can occur, it is not the most common characteristic associated with nephrotic syndrome. The primary physiological change is the massive proteinuria leading to hypoproteinemia and subsequent edema. Hypertension may develop as a result of volume overload, but it is not a hallmark sign. The most prominent and defining symptom is the severe edema.
Correct Answer is D
Explanation
Choice A rationale
Succimer is a chelating agent used to treat heavy metal poisoning, such as lead or arsenic toxicity. It works by binding to these metals and facilitating their excretion from the body. It is not indicated for the treatment of acetaminophen toxicity, which requires a different mechanism of action to counteract the toxic metabolite.
Choice B rationale
Atropine is an anticholinergic medication used to treat bradycardia or to counteract the effects of cholinergic drugs. It works by blocking the action of acetylcholine at muscarinic receptors. Its mechanism of action is unrelated to acetaminophen toxicity and it would not be an appropriate treatment.
Choice C rationale
Syrup of ipecac is an emetic used to induce vomiting. The use of emetics is no longer recommended for the treatment of most poisonings due to the risk of aspiration and lack of evidence for improved outcomes. Its use is contraindicated in cases of acetaminophen toxicity.
Choice D rationale
Acetylcysteine is the antidote for acetaminophen toxicity. It works by replenishing glutathione stores in the liver. Glutathione is essential for detoxifying the toxic metabolite of acetaminophen, N-acetyl-p-benzoquinone imine (NAPQI). A normal serum acetaminophen level is less than 10 mcg/mL.
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