A nurse assesses a postpartum client who is 6 hours post-vaginal delivery. The fundus is noted to be above the umbilicus and deviated to the right. What is the priority nursing action?
Encourage the client to void and reassess the fundus.
Perform a fundal massage to promote contraction.
Notify the health care provider immediately.
Assess for retained placental fragments.
The Correct Answer is A
Choice A reason: A fundus above the umbilicus and deviated to the right indicates bladder distention. Encouraging the client to void relieves bladder pressure, allowing the uterus to contract normally and return to midline.
Choice B reason: Fundal massage is indicated for uterine atony, not bladder distention. Massage will not correct displacement caused by a full bladder.
Choice C reason: Immediate notification of the provider is not necessary until nursing interventions fail. Voiding is the first-line intervention.
Choice D reason: Retained placental fragments cause uterine atony and abnormal bleeding, not fundal deviation. The clinical picture here is consistent with bladder distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Drawing CBC and blood cultures is indicated when there is suspicion of infection, particularly with persistent fever or abnormal clinical signs. A temperature of 100.4°F within the first 24 hours postpartum is considered a normal physiological response to exertion during labor, dehydration, or breast engorgement, not necessarily infection.
Choice B reason: Monitoring the client’s temperature is appropriate because a mild elevation in temperature within the first 24 hours postpartum is common and usually resolves spontaneously. Continued monitoring ensures that if the temperature rises above 100.4°F after 24 hours or persists, infection can be promptly identified.
Choice C reason: Immediate reporting is not necessary for a single mild elevation in temperature within the first hour postpartum. It is not considered a critical finding unless accompanied by other abnormal signs.
Choice D reason: Administering Tylenol STAT is not warranted unless the client is symptomatic or the temperature is higher. Routine antipyretic administration for mild, expected postpartum temperature elevation is unnecessary.
Correct Answer is C
Explanation
Choice A reason: Administering the highest effective dose is unsafe. Oxytocin must be titrated carefully because excessive dosing can cause uterine tachysystole, fetal distress, or uterine rupture.
Choice B reason: Intermittent monitoring is not appropriate with oxytocin infusion. Continuous monitoring is required because oxytocin increases risk of fetal compromise and uterine hyperstimulation.
Choice C reason: Administering the dose as ordered is the correct consideration. Nurses must follow prescribed protocols, titrate carefully, and monitor maternal-fetal response. This ensures safe induction while minimizing risks.
Choice D reason: Discontinuing oxytocin for reassuring fetal heart patterns is incorrect. Oxytocin should be discontinued if fetal heart patterns become non-reassuring or if uterine tachysystole occurs, not when patterns are reassuring.
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