A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following Interventions should the nurse perform?
Reassess the client in 2 hr.
Administer simethicone.
Assist the client to empty her bladder.
Instruct the client to lie on her right side.
The Correct Answer is C
Choice A Reason:
Reassess the client in 2 hours is inappropriate. While reassessment is important, addressing the cause of uterine displacement, in this case, a full bladder, should be the initial priority.
Choice B Reason:
Administering simethicone is inappropriate. Simethicone is typically used to relieve gas and bloating. It is not the primary intervention for uterine displacement related to bladder fullness.
Choice C Reason:
Assisting the client to empty her bladder is appropriate. A full bladder can displace the uterus and hinder its contraction, leading to potential issues such as uterine atony or increased postpartum bleeding. Emptying the bladder helps the uterus contract more effectively.
Choice D Reason:
Instructing the client to lie on her right side is inappropriate. Lying on the right side is often recommended to improve blood flow and oxygenation to the fetus during pregnancy but may not directly address uterine displacement caused by a full bladder. The priority is to assist the client in emptying her bladder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The cervix being effaced is not represented by the -1 notation in a vaginal examination. Effacement is usually expressed as a percentage.
B. The -1 notation does not represent cervical dilation. Dilation is measured in centimeters.
C. The presenting part being 1 cm below the ischial spines is not correct. In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
D. The presenting part is 1 cm above the ischial spines is the correct interpretation.
In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
Correct Answer is C
Explanation
The correct answer is C. Hypotension.
A. Respiratory depression is not a common complication of epidural anesthesia. It is more associated with opioid analgesics or excessive administration of other anesthetics.
B. Tachycardia is generally not associated with epidural anesthesia. It is more commonly observed in response to pain or anxiety.
C. Hypotension is a common complication of epidural anesthesia.
Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. This is particularly common when the block is administered rapidly or with a higher dose.
D. Vomiting is not a direct complication of epidural anesthesia. Nausea and vomiting are more commonly associated with opioid analgesics or general anesthesia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today